2023-2024 ATI RN Maternal Newborn Proctored Exam With Answers-441 Solved Questions

2024 ATI RN MATERNAL NEWBORN PROCTORED 2023 FINAL
VERSION EXAM WITH GUARANTEED DISTINCTION ANSWERS
FROM EXPERT DOWNLOAD TO SCORE A+
1) Which of the following is a potential complication of oligohydramnios?
A. Preterm labor
B. Fetal growth restriction
C. Polyhydramnios
D. All of the above
Answer: B. Fetal growth restriction Intrapartum:
2) Which stage of labor is characterized by the period between the end of the third stage and
the mother's recovery from delivery?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
Answer: D. Fourth stage
3) What is the recommended method of pain relief during labor for a woman with a high- risk
pregnancy?
A. Epidural anesthesia
B. Spinal anesthesia
C. Intravenous opioids
D. All of the above
Answer: A. Epidural anesthesia
4) Which of the following is a potential complication of a vacuum-assisted delivery?
A. Fetal distress
B. Maternal hemorrhage
C. Intra-abdominal injury
D. All of the above
Answer: C. Intra-abdominal injury Postpartum:

5) Which of the following is a potential complication of a retained placenta?
A. Preeclampsia
B. Postpartum hemorrhage
C. Gestational diabetes
D. All of the above
Answer: B. Postpartum hemorrhage
6) A nurse is caring for a client who is in active labor and has had no cervical change in the
last 4 hours. Which of the following statements should the nurse make?
Answer: Your provider will insert an intrauterine pressure catheter to monitor the strength of
your contractions.
Rationale:
Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction
intensity, which will identify whether or not the contractions are adequate for the progression
of labor.
7) A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock.
After notifying the provider, which of the following actions should the nurse take next?
Answer: Massage the client’s fundus.
Rationale:
The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take
is to massage the client’s fundus to expel clots and promote contractions.
8) A nurse is reviewing the medical record of a client who is one day postpartum. The client
had a vaginal birth with a fourth- degree perineal laceration. The nurse should contact the
provider regarding which of the following prescriptions?
Answer: Bisacodyl rectal suppository daily as needed for constipation
Rationale:
The nurse should not administer a rectal suppository or enema to a client who has a fourthdegree perineal laceration. These can cause separation of the suture line, bleeding, or
infection.

9) A nurse is caring for a client who is at 26 weeks gestation and has epilepsy. The nurse
enters the room and observes the client having a seizure. After turning the client’s head to one
side, which of the following actions should the nurse take immediately after the seizure?
Answer: Administer oxygen via a nonrebreather mask.
Rationale:
When using the airway, breathing, and circulation approach to client care, the nurse should
place the priority on administering oxygen to the client via a nonrebreather mask to ensure
adequate oxygenation to mother and fetus.
10) A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2
weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the
following responses should the nurse make?
Answer: “You can miss your period for several other reasons. Describe your typical
menstrual cycle”.
Rationale:
Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse
should explore the client’s menstrual cycle to determine other necessary interventions.
11) A nurse is providing discharge teaching to a client who is postpartum and was taking
insulin for gestational diabetes mellitus. Which of the following instructions should the nurse
include in the teaching?
Answer: “You should get a 2-hour oral glucose tolerance test in 6-12 weeks.”
Rationale:
The nurse should instruct the client to get 2-hour oral glucose tolerance test 6-12 weeks
postpartum and every 3 years to screen for type 2 diabetes. The nurse should instruct the
client that blood glucose levels return to the expected reference range after childbirth.
Therefore, the client does not need to monitor her blood glucose levels or continue the insulin
at home.
12) What is the recommended method of pain relief for a woman who has a perineal
laceration after delivery?
A. Nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Acetaminophen
C. Sitz baths

D. All of the above
Answer: D. All of the above
13) Which of the following is a potential complication of neonatal hyperbilirubinemia?
A. Hypoglycemia
B. Kernicterus
C. Respiratory distress syndrome
D. All of the above
Answer: B. Kernicterus
Newborn Care:
14) What is the recommended method of administering the first dose of hepatitis B vaccine to
a newborn?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Sub cut
Answer: A. Intramuscular injection
15) Which of the following is a potential complication of neonatal respiratory distress
syndrome?
A. Hypoglycemia
B. Pneumonia
C. Patent ductus arteriosus
D. All of the above
Answer: D. All of the above
16) What is the recommended method of administering vitamin K to a newborn who is at risk
for bleeding?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection

Answer: A. Intramuscular injection
Professional Practice:
17) What is the primary responsibility of a nurse or midwife in advocating for patient and
family-centered care in maternal and newborn healthcare?
A. Promoting shared decision- making
B. Ensuring patient privacy and confidentiality
C. Providing evidence-based care
D. All of the above
Answer: A. Promoting shared decision-making
18) Which of the following is a potential barrier to implementing evidence based practice in
maternal and newborn healthcare?
A. Resistance to change
B. Limited access to technology
C. Lack of funding
D. All of the above
Answer: D. All of the above
19) Which of the following is a potential ethical issue related to the use of assisted
reproductive technologies in maternal and newborn healthcare?
A. Use of donor gametes
B. Multiple gestation pregnancies
C. Preimplantation genetic diagnosis (PGD)
D. All of the above
Answer: D. All of the above
20) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Collaboration with patients and families
B. Continuity of care
C. Cultural competence
D. All of the above

Answer: D. All of the above
21) Which of the following is a potential legal issue related to maternal and newborn
healthcare?
A. Informed consent
B. Medical malpractice
C. Abandonment
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:
22) Which of the following hormones is responsible for stimulating uterine contractions
during labor?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: D. Oxytocin
23) What is the function of the cervix during pregnancy?
A. To secrete mucus that prevents infection
B. To protect the fetus from trauma
C. To regulate fetal temperature
D. All of the above
Answer: A. To secrete mucus that prevents infection
24) Which of the following is a potential cause of male infertility?
A. Varicocele
B. Cryptorchidism
C. Testicular cancer
D. All of the above
Answer: D. All of the above

Antepartum:
25) Which of the following is a potential complication of maternal hypertension during
pregnancy?
A. Preterm labor
B. Fetal growth restriction
C. Placental abruption
D. All of the above
Answer: D. All of the above
26) What is the recommended method of screening for Down syndrome during pregnancy?
A. Maternal serum screening
B. Fetal ultrasound
C. Chorionic villus sampling (CVS)
D. Amniocentesis
Answer: A. Maternal serum screening
27) Which of the following is a potential complication of a nuchal cord?
A. Fetal distress
B. Maternal hemorrhage
C. Amniotic fluid embolism
D. All of the above
Answer: A. Fetal distress
Intrapartum:
28) Which stage of labor is characterized by the period between the onset of regular
contractions and full cervical dilation?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
Answer: A. First stage

29) What is the recommended method of pain relief during labor for a woman who wants to
avoid medication?
A. Acupuncture
B. Massage
C. Water immersion
D. All of the above
Answer: D. All of the above
30) Which of the following is a potential complication of a breech delivery?
A. Fetal distress
B. Maternal hemorrhage
C. Birth trauma
D. All of the above
Answer: C. Birth trauma Postpartum:
31) Which of the following is a potential complication of a postpartum infection?
A. Septicemia
B. Anemia
C. Thrombocytopenia
D. All of the above
Answer: A. Septicemia
32) What is the recommended method of feeding for a premature infant?
A. Breastfeeding
B. Formula feeding
C. Tube feeding
D. All of the above
Answer: C. Tube feeding
33) Which of the following is a potential complication of neonatal hypothermia?
A. Hypoglycemia
B. Respiratory distress syndrome
C. Jaundice
D. All of the above

Answer: D. All of the above Newborn Care:
34) What is the recommended method of administering vitamin K to a newborn who is not at
risk for bleeding?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection
Answer: B. Oral administration
35) Which hormone is responsible for stimulating the growth and development of the ovarian
follicles?
A. Estrogen
B. Progesterone
C. Follicle-stimulating hormone (FSH)
D. Luteinizing hormone (LH)
Answer: C. Follicle-stimulating hormone (FSH)
36) Which of the following hormones is responsible for inducing ovulation?
A. Estrogen
B. Progesterone
C. Follicle-stimulating hormone (FSH)
D. Luteinizing hormone (LH)
Answer: D. Luteinizing hormone (LH)
37) What is the primary hormone responsible for maintaining the endometrium during
pregnancy?
A. Progesterone
B. Estrogen
C. Follicle-stimulating hormone (FSH)
D. Luteinizing hormone (LH)
Answer: A. Progesterone
Antepartum:

38) Which of the following tests is used to assess fetal lung maturity?
A. Non-stress test
B. Biophysical profile
C. Amniocentesis
D. Lecithin-sphingomyelin (L/S) ratio
Answer: D. Lecithin-sphingomyelin (L/S) ratio
39) What is the recommended amount of weight gain during pregnancy for a woman with a
normal BMI?
A. 10-15 pounds
B. 20-30 pounds
C. 30-40 pounds
D. 40-50 pounds
Answer: B. 20-30 pounds
40) Which of the following is a potential complication of gestational diabetes?
A. Hyperglycemia
B. Hypoglycemia
C. Polyhydramnios
D. Hypertension
Answer: C. Polyhydramnios Intrapartum:
41) Which stage of labor is characterized by cervical dilation from 4-10 cm?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
Answer: A. First stage
42) What is the most common type of anesthesia used during labor?
A. Epidural
B. Spinal
C. General

D. Local
Answer: A. Epidural
43) Which of the following is a potential complication of a vaginal delivery?
A. Shoulder dystocia
B. Placenta previa
C. Umbilical cord prolapse
D. Cephalopelvic disproportion
Answer: A. Shoulder dystocia
Postpartum:
44) What is the recommended method of contraception for a woman who is breastfeeding?
A. Combined oral contraceptives
B. Depo-Provera injection
C. Copper intrauterine device (IUD)
D. Progestin-only pills
Answer: D. Progestin-only pills
45) Which of the following is a potential complication of a cesarean delivery?
A. Postpartum hemorrhage
B. Infection
C. Deep vein thrombosis (DVT)
D. All of the above
Answer: D. All of the above
46) What is the primary intervention for postpartum hemorrhage?
A. Oxytocin infusion
B. Methylergonovine injection
C. Misoprostol administration
D. Blood transfusion
Answer: A. Oxytocin infusion
Newborn Care:

47) What is the recommended age for the first hepatitis B vaccine for a newborn?
A. At birth
B. within 48 hours of birth
C. within 1 week of birth
D. within 1 month of birth
Answer: B. Within 48 hours of birth
48) What is the recommended method of feeding for a preterm infant?
A. Breastfeeding
B. Formula feeding
C. Bottle feeding with breast milk
D. Parenteral nutrition
Answer: C. Bottle feeding with breast milk
49) Which of the following is a potential complication of jaundice in a newborn?
A. Kernicterus
B. Hypoglycemia
C. Respiratory distress
D. Sepsis
Answer: A. Kernicterus
Professional Practice:
50) What is the primary ethical principle guiding nursing practice in maternal and newborn
healthcare?
A. Autonomy
B. Non-maleficence
C. Beneficence
D. Justice
Answer: C. Beneficence
51) Which of the following is a potential barrier to providing culturally competent care in
maternal and newborn healthcare?

A. Lack of awareness of cultural differences
B. Bias and prejudice
C. Limited access to resources
D. All of the above
Answer: D. All of the above
52) Which of the following is a legal issue related to maternal and newborn healthcare?
A. Informed consent
B. Patient confidentiality
C. Malpractice
D. All of the above
Answer: D. All of the above
53) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Evidence-based practice
B. Continuing education
C. Professional development
D. All of the above
Answer: D. All of the above
54) What is the primary role of a nurse or midwife in maternal and newborn healthcare?
A. Providing direct patient care
B. Conducting research
C. Teaching patients and families
D. All of the above
Answer: A. Providing direct patient care
Anatomy and Physiology:
55) What is the primary hormone responsible for stimulating ovulation?
A. Progesterone
B. Estrogen
C. Follicle-stimulating hormone (FSH)

D. Luteinizing hormone (LH)
Answer: D. Luteinizing hormone (LH)
56) What is the function of the placenta during pregnancy?
A. To nourish and protect the fetus
B. To produce hormones that support pregnancy
C. To facilitate gas exchange between the mother and fetus
D. All of the above
Answer: D. All of the above
57) Which of the following hormones is responsible for preparing the uterus for
implantation?
A. Progesterone
B. Estrogen
C. Follicle-stimulating hormone (FSH)
D. Luteinizing hormone (LH)
Answer: A. Progesterone
Antepartum:
58) Which of the following conditions is a risk factor for preterm labor?
A. Preeclampsia
B. Gestational diabetes
C. Polyhydramnios
D. All of the above
Answer: D. All of the above
59) What is the recommended frequency for prenatal visits for a woman with a normal
pregnancy?
A. Monthly until 28 weeks, then every 2 weeks until 36 weeks, then weekly until delivery
B. Every 4 weeks until 36 weeks, then every 2 weeks until delivery
C. Every 2 weeks until 36 weeks, then weekly until delivery
D. Every week until delivery

Answer: A. Monthly until 28 weeks, then every 2 weeks until 36 weeks, then weekly until
delivery
60) Which of the following is a potential complication of hypertension in pregnancy?
A. Preterm labor
B. Fetal distress
C. Placenta previa
D. All of the above
Answer: B. Fetal distress
Intrapartum:
61) Which stage of labor is characterized by the birth of the baby?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
Answer: B. Second stage
62) What is the recommended method of pain relief during labor for a woman who wants to
avoid medication?
A. Breathing techniques
B. Massage
C. Water immersion
D. All of the above
Answer: D. All of the above
63) Which of the following is a potential complication of a cesarean delivery?
A. Hemorrhage
B. Infection
C. Uterine rupture
D. All of the above
Answer: D. All of the above

Postpartum:
64) Which of the following is a potential complication of postpartum depression?
A. Poor bonding with the newborn
B. Insufficient milk production
C. Increased risk of postpartum hemorrhage
D. All of the above
Answer: A. Poor bonding with the newborn
65) What is the recommended method of pain relief for a woman who has a vaginal tear or
episiotomy after delivery?
A. Nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Acetaminophen
C. Ice packs
D. All of the above
Answer: D. All of the above
66) What is the recommended method of feeding for a term infant?
A. Breastfeeding
B. Formula feeding
C. Bottle feeding with breast milk
D. Parenteral nutrition
Answer: A. Breastfeeding
Newborn Care:
67) Which of the following is a potential complication of meconium aspiration syndrome?
A. Respiratory distress syndrome
B. Hypoglycemia
C. Jaundice
D. All of the above
Answer: A. Respiratory distress syndrome
68) What is the recommended method of administering vitamin K to a newborn?

A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection
Answer: A. Intramuscular injection
69) Which of the following is a potential complication of hypothermia in a newborn?
A. Hypoglycemia
B. Respiratory distress syndrome
C. Hypertension
D. All of the above
Answer: B. Respiratory distress syndrome
Professional Practice:
70) What is the primary legal responsibility of a nurse or midwife in maternal and newborn
healthcare?
A. Ensuring patient safety
B. Maintaining patient confidentiality
C. Providing appropriate care and treatment
D. All of the above
Answer: D. All of the above
71) Which of the following is a potential barrier to effective communication with patients and
families in maternal and newborn healthcare?
A. Language barriers
B. Cultural differences
C. Limited access to technology
D. All of the above
Answer: D. All of the above
72) Which of the following is a potential ethical issue in maternal and newborn healthcare?
A. Informed consent
B. Patient confidentiality

C. End-of-life decision-making
D. All of the above
Answer: D. All of the above
73) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Collaboration with interdisciplinary team members
B. Advocacy for patients and families
C. Incorporation of evidence-based practice
D. All of the above
Answer: D. All of the above
74) Which of the following is a potential legal issue related to informed consent in maternal
and newborn healthcare?
A. Failure to obtain informed consent
B. Lack of understanding by the patient or family
C. Coercion or duress in obtaining consent
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:
75) What is the role of the fallopian tubes in fertilization?
A. Production of ova
B. Production of sperm
C. Transport of ova to the uterus
D. Transport of sperm to the uterus
Answer: C. Transport of ova to the uterus
76) Which hormone is responsible for stimulating milk production in the breasts?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin

Answer: C. Prolactin
77) What is the function of the amniotic fluid during pregnancy?
A. To protect the fetus from trauma
B. To regulate fetal temperature
C. To facilitate fetal movement
D. All of the above
Answer: D. All of the above Antepartum:
78) Which of the following is a potential complication of a multiple gestation pregnancy?
A. Preterm labor
B. Gestational diabetes
C. Placenta previa
D. All of the above
Answer: D. All of the above
79) What is the recommended method of screening for gestational diabetes?
A. Random blood glucose test
B. Fasting blood glucose test
C. Oral glucose tolerance test
D. Hemoglobin A1C test
Answer: C. Oral glucose tolerance test
80) Which of the following is a potential complication of a placental abruption?
A. Preterm labor
B. Fetal distress
C. Polyhydramnios
D. All of the above
Answer: B. Fetal distress
Intrapartum:
81) Which stage of labor is characterized by the delivery of the placenta?
A. First stage

B. Second stage
C. Third stage
D. Fourth stage
Answer: C. Third stage
82) What is the recommended method of pain relief during labor for a woman with a lowrisk pregnancy?
A. Epidural anesthesia
B. Spinal anesthesia
C. Nitrous oxide inhalation
D. All of the above
Answer: C. Nitrous oxide inhalation
83) Which of the following is a potential complication of a forceps-assisted delivery?
A. Shoulder dystocia
B. Hemorrhage
C. Birth trauma
D. All of the above
Answer: C. Birth trauma Postpartum:
84) Which of the following is a potential complication of a postpartum hemorrhage?
A. Hypertension
B. Anemia
C. Thrombocytopenia
D. All of the above
Answer: B. Anemia
85) What is the recommended method of pain relief for a woman who has a caesarean
delivery?
A. Epidural anesthesia
B. Intravenous opioids
C. Patient controlled analgesia
D. All of the above
Answer: D. All of the above

86) Which of the following is a potential complication of a preterm infant?
A. Hypoglycemia
B. Respiratory distress syndrome
C. Hyperbilirubinemia
D. All of the above
Answer: D. All of the above
Newborn Care:
87) What is the recommended method of administering erythromycin ointment to a newborn?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection
Answer: C. Topical application
88) Which of the following is a potential complication of neonatal sepsis?
A. Hypoglycemia
B. Respiratory distress syndrome
C. Meningitis
D. All of the above
Answer: D. All of the above
89) What is the recommended method of administering hepatitis B vaccine to a newborn?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection
Answer: A. Intramuscular injection
90) Which of the following is a potential complication of hypoglycemia in a newborn?
A. Hypothermia
B. Hyperbilirubinemia

C. Respiratory distress syndrome
D. All of the above
Answer: D. All of the above
Professional Practice:
91) What is the primary goal of culturally competent care in maternal and newborn
healthcare?
A. To eliminate cultural differences
B. To promote health equity
C. To prioritize the healthcare provider's cultural background
D. All of the above
Answer: B. To promote health equity
92) Which of the following is a potential barrier to providing patient-centered care in
maternal and newborn healthcare?
A. Lack of communication skills
B. Lack of knowledge and expertise
C. Lack of cultural awareness
D. All of the above
Answer: D. All of the above
93) Which of the following is a potential ethical issue related to pain management in maternal
and newborn healthcare?
A. Undertreatment of pain
B. Overtreatment of pain
C. Use of alternative therapies without informed consent
D. All of the above
Answer: D. All of the above
94) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Promotion of health equity
B. Provision of patient-centered care

C. Advocacy for social justice
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:
95) Which of the following is a potential cause of female infertility?
A. Endometriosis
B. Polycystic ovary syndrome (PCOS)
C. Pelvic inflammatory disease (PID)
D. All of the above
Answer: D. All of the above
96) Which hormone is responsible for triggering milk ejection during breastfeeding?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: D. Oxytocin
97) What is the function of the umbilical cord during pregnancy?
A. To transport oxygen and nutrients from the mother to the fetus
B. To remove waste products from the fetus
C. To regulate fetal temperature
D. All of the above
Answer: A. To transport oxygen and nutrients from the mother to the fetus
Antepartum:
98) Which of the following is a potential complication of maternal obesity during pregnancy?
A. Gestational diabetes
B. Preterm labor
C. Placental abruption
D. All of the above

Answer: D. All of the above
99) What is the recommended method of screening for Group B Streptococcus (GBS) during
pregnancy?
A. Urine culture
B. Rectovaginal culture
C. Blood test
D. Nasopharyngeal culture
Answer: B. Rectovaginal culture
100) Which of the following is a potential complication of neonatal hypocalcemia?
A. Hypoglycemia
B. Seizures
C. Respiratory distress syndrome
D. All of the above
Answer: B. B. Seizures
101) What is the recommended method of administering the second dose of hepatitis B
vaccine to a newborn?
A. Intramuscular injection
B. Oral administration
C. Topical application
D. Subcutaneous injection
Answer: A. Intramuscular injection
Professional Practice:
102) What is the primary goal of patient education in maternal and newborn healthcare?
A. To improve health outcomes
B. To increase patient satisfaction
C. To decrease healthcare costs
D. All of the above
Answer: A. To improve health outcomes

103) Which of the following is a potential barrier to effective communication in maternal and
newborn healthcare?
A. Limited health literacy
B. Cultural differences
C. Language barriers
D. All of the above
Answer: D. All of the above
104) Which of the following is a potential ethical issue related to neonatal intensive care?
A. Allocation of resources
B. Withholding or withdrawing life sustaining treatment
C. Use of alternative therapies without informed consent
D. All of the above
Answer: D. All of the above
105) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Safety and quality improvement
B. Patient-centered care
C. Leadership
D. All of the above
Answer: D. All of the above
106) Which of the following is a potential legal issue related to informed consent in maternal
and newborn healthcare?
A. Lack of capacity to consent
B. Coercion or undue influence
C. Failure to disclose risks and benefits
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:

107) Which of the following hormones is responsible for the growth and development of the
mammary glands during pregnancy?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: C. Prolactin
108) What is the function of the placenta during pregnancy?
A. To transport oxygen and nutrients from the mother to the fetus
B. To remove waste products from the fetus
C. To regulate fetal temperature
D. All of the above
Answer: D. All of the above
109) Which of the following is a potential cause of male infertility?
A. Azoospermia
B. Oligospermia
C. Teratospermia
D. All of the above
Answer: D. All of the above Antepartum:
110) Which of the following is a potential complication of maternal hypothyroidism during
pregnancy?
A. Preterm labor
B. Fetal growth restriction
C. Preeclampsia
D. All of the above
Answer: D. All of the above
111) What is the recommended method of screening for gestational diabetes during
pregnancy?
A. Fasting blood glucose test
B. Random blood glucose test

C. Oral glucose tolerance test (OGTT)
D. HbA1c test
Answer: C. Oral glucose tolerance test (OGTT)
112) Which of the following is a potential complication of placenta previa?
A. Preterm labor
B. Fetal growth restriction
C. Placental abruption
D. All of the above
Answer: C. Placental abruption Intrapartum:
113) Which stage of labor is characterized by the period between full cervical dilation and
delivery of the fetus?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
Answer: B. Second stage
114) What is the recommended method of pain relief during labor for a woman who wants to
avoid medication and wants to move around freely?
A. Nitrous oxide
B. Intramuscular opioids
C. Transcutaneous electrical nerve stimulation (TENS)
D. All of the above
Answer: A. Nitrous oxide
115) Which of the following is a potential complication of a forceps assisted delivery?
A. Fetal distress
B. Maternal hemorrhage
C. Neonatal brachial plexus injury
D. All of the above
Answer: C. Neonatal brachial plexus injury

Postpartum:
116) Which of the following is a potential complication of a postpartum hemorrhage?
A. Disseminated intravascular coagulation (DIC)
B. Anemia
C. Hyperglycemia
D. All of the above
Answer: A. Disseminated intravascular coagulation (DIC)
117) What is the recommended method of feeding for a full-term newborn who is not at risk
for hypoglycemia?
A. Breastfeeding
B. Formula feeding
C. Tube feeding
D. All of the above
Answer: A. Breastfeeding
118) Which of the following is a potential complication of neonatal hypoglycemia?
A. Jaundice
B. Respiratory distress syndrome
C. Intraventricular hemorrhage
D. All of the above
Answer: D. All of the above
Newborn Care:
119) What is the recommended method of administering vitamin D to a breastfed newborn?
A. Intramuscular injection
B. Oral drops
C. Topical application
D. Subcutaneous injection
Answer: B. Oral drops
120) Which of the following is a potential complication of neonatal hyperbilirubinemia?

A. Dehydration
B. Kernicterus
C. Hypoglycemia
D. All of the above
Answer: B. Kernicterus
Professional Practice:
121) What is the primary responsibility of a nurse or midwife in providing culturally
competent care in maternal and newborn healthcare?
A. Recognizing and respecting cultural diversity
B. Providing culturally sensitive education
C. Addressing health disparities
D. All of the above
Answer: D. All of the above
122) Which of the following is a potential barrier to patient safety in maternal and newborn
healthcare?
A. Medication errors
B. Inadequate staffing
C. Patient noncompliance
D. All of the above
Answer: D. All of the above
123) Which of the following is a potential ethical issue related to fetal surgery?
A. Informed consent
B. Allocation of resources
C. End-of-life decision making
D. All of the above
Answer: A. Informed consent
124) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Interprofessional collaboration

B. Evidence-based practice
C. Quality improvement
D. All of the above
Answer: D. All of the above
125) Which of the following is a potential legal issue related to maternal and newborn
healthcare?
A. Medical negligence
B. Patient confidentiality
C. Informed consent
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:
126) Which of the following hormones is responsible for maintaining the uterine lining
during pregnancy?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: A. Progesterone
127) What is the function of the amniotic fluid during pregnancy?
A. To protect the fetus from infection
B. To cushion the fetus from physical trauma
C. To regulate fetal temperature
D. All of the above
Answer: D. All of the above
128) Which of the following is a potential cause of female infertility?
A. Polycystic ovary syndrome (PCOS)
B. Endometriosis
C. Pelvic inflammatory disease (PID)

D. All of the above
Answer: D. All of the above
Antepartum:
129) Which of the following is a potential complication of maternal hyperthyroidism during
pregnancy?
A. Preterm labor
B. Fetal growth restriction
C. Preterm premature rupture of membranes (PPROM)
D. All of the above
Answer: D. All of the above
130) What is the recommended method of screening for syphilis during pregnancy?
A. Venereal disease research laboratory (VDRL) test
B. Rapid plasma reagin (RPR) test
C. Fluorescent treponemal antibody absorption (FTA-ABS) test
D. All of the above
Answer: D. All of the above
131) Which of the following is a potential complication of gestational hypertension?
A. Preterm labor
B. Fetal growth restriction
C. Placental abruption
D. All of the above
Answer: D. All of the above
Intrapartum:
132) Which stage of labor is characterized by the period between the onset of regular uterine
contractions and full cervical dilation?
A. First stage
B. Second stage
C. Third stage

D. Fourth stage
Answer: A. First stage
133) What is the recommended method of pain relief during labor for a woman who wants to
avoid medication and prefers non-pharmacologic interventions?
A. Nitrous oxide
B. Intramuscular opioids
C. Transcutaneous electrical nerve stimulation (TENS)
D. All of the above
Answer: C. Transcutaneous electrical nerve stimulation (TENS)
134) Which of the following is a potential complication of a vacuum assisted delivery?
A. Fetal distress
B. Maternal hemorrhage
C. Neonatal cephalohematoma
D. All of the above
Answer: D. All of the above
Postpartum:
135) What is the recommended method of feeding for a preterm newborn who is not yet able
to coordinate sucking and swallowing?
A. Breastfeeding
B. Formula feeding
C. Tube feeding
D. All of the above
Answer: C. Tube feeding
136) Which of the following is a potential complication of neonatal hypothermia?
A. Hypoglycemia
B. Hyperglycemia
C. Respiratory distress syndrome
D. All of the above
Answer: A. Hypoglycemia

Professional Practice:
137) What is the primary goal of interprofessional collaboration in maternal and newborn
healthcare?
A. To improve communication and coordination of care
B. To decrease healthcare costs
C. To increase patient satisfaction
D. All of the above
Answer: A. To improve communication and coordination of care
138) Which of the following is a potential barrier to effective interprofessional collaboration
in maternal and newborn healthcare?
A. Hierarchical structures and power differentials
B. Lack of understanding of other professions' roles and responsibilities
C. Limited resources
D. All of the above
Answer: D. All of the above
139) Which of the following is a potential ethical issue related to neonatal palliative care?
A. Withholding or withdrawing life-sustaining treatment
B. Allocation of resources
C. Use of alternative therapies without informed consent
D. All of the above
Answer: A. Withholding or withdrawing life-sustaining treatment
140) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Education and lifelong learning
B. Research and scholarship
C. Collaboration
D. All of the above
Answer: D. All of the above

141) Which of the following is a potential legal issue related to maternal and newborn
healthcare?
A. Medical malpractice
B. Patient autonomy
C. Informed refusal
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:
142) Which of the following hormones stimulates uterine contractions during labor?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: D. Oxytocin
143) What is the function of the umbilical cord during fetal development?
A. To transport oxygen and nutrients from the mother to the fetus
B. To remove waste products from the fetus
C. To regulate fetal temperature
D. All of the above
Answer: D. All of the above
144) Which of the following is a potential cause of recurrent pregnancy loss?
A. Chromosomal abnormalities
B. Immunologic factors
C. Environmental factors
D. All of the above
Answer: D. All of the above
Antepartum:

145) Which of the following is a potential complication of maternal hyperemesis
gravidarum?
A. Preterm labor
B. Fetal growth restriction
C. Maternal dehydration
D. All of the above
Answer: D. All of the above
146) What is the recommended method of screening for hepatitis B during pregnancy?
A. Hepatitis B surface antigen (HBsAg) test
B. Hepatitis B core antibody (HBcAb) test
C. Hepatitis B e antigen (HBeAg) test
D. All of the above
Answer: A. Hepatitis B surface antigen (HBsAg) test
147) Which of the following is a potential complication of gestational diabetes?
A. Polyhydramnios
B. Preterm labor
C. Neonatal hypoglycemia
D. All of the above
Answer: D. All of the above Intrapartum:
148) Which of the following is a potential indication for induction of labor?
A. Preeclampsia
B. Gestational diabetes
C. Fetal macrosomia
D. All of the above
Answer: A. Preeclampsia
149) What is the recommended method of pain relief during labor for a woman who desires
regional anesthesia?
A. Epidural block
B. Spinal block
C. Combined spinal-epidural block

D. All of the above
Answer: D. All of the above
150) Which of the following is a potential complication of a caesarean delivery?
A. Maternal infection
B. Neonatal respiratory distress syndrome
C. Postoperative hemorrhage
D. All of the above
Answer: D. All of the above Postpartum:
151) What is the recommended method of feeding for a newborn with galactosemia?
A. Breastfeeding
B. Formula feeding
C. Soy-based formula feeding
D. All of the above
Answer: B. Formula feeding
152) Which of the following is a potential complication of neonatal hypernatremia?
A. Hyperglycemia
B. Hypoglycemia
C. Dehydration
D. All of the above
Answer: C. Dehydration
Professional Practice:
153) Which of the following is a potential benefit of patient-centered care in maternal and
newborn healthcare?
A. Increased patient satisfaction
B. Improved health outcomes
C. Decreased healthcare costs
D. All of the above
Answer: D. All of the above

154) Which of the following is a potential barrier to patient-centered care in maternal and
newborn healthcare?
A. Lack of cultural competence
B. Provider bias
C. Limited resources
D. All of the above
Answer: D. All of the above
155) Which of the following is a potential ethical issue related to neonatal organ donation?
A. Informed consent
B. Allocation of resources
C. End-of life decision making
D. All of the above
Answer: A. Informed consent
156) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Leadership
B. Technology and informatics
C. Ethics
D. All of the above
Answer: D. All of the above
157) Which of the following is a potential legal issue related to maternal and newborn
healthcare?
A. Informed consent
B. Patient confidentiality
C. Medical malpractice
D. All of the above
Answer: D. All of the above
Anatomy and Physiology:

158) Which of the following hormones is responsible for stimulating milk production during
lactation?
A. Progesterone
B. Estrogen
C. Prolactin
D. Oxytocin
Answer: C. Prolactin
159) What is the function of the placenta during pregnancy?
A. To protect the fetus from infection
B. To remove waste products from the fetus
C. To facilitate nutrient and gas exchange between the mother and fetus
D. All of the above
Answer: D. All of the above
160) Which of the following is a potential cause of male infertility?
A. Varicocele
B. Testicular cancer
C. Erectile dysfunction
D. All of the above
Answer: D. All of the above
Antepartum:
161) Which of the following is a potential complication of maternal hypertension during
pregnancy?
A. Placental abruption
B. Fetal growth restriction
C. Preterm labor
D. All of the above
Answer: D. All of the above
162) What is the recommended method of screening for group B streptococcus during
pregnancy?

A. Culture of a vaginal swab
B. Rapid antigen test of a vaginal swab
C. PCR test of a vaginal swab
D. All of the above
Answer: A. Culture of a vaginal swab
163) Which of the following is a potential complication of maternal obesity during
pregnancy?
A. Gestational diabetes
B. Preterm labor
C. Fetal macrosomia
D. All of the above
Answer: D. All of the above Intrapartum:
164) Which of the following is a potential indication for a forceps-assisted delivery?
A. Fetal distress
B. Maternal hemorrhage
C. Prolonged second stage of labor
D. All of the above
Answer: C. Prolonged second stage of labor
165) What is the recommended method of pain relief during labor for a woman who desires
systemic opioids?
A. Intravenous opioids
B. Intramuscular opioids
C. Oral opioids
D. All of the above
Answer: A. Intravenous opioids
166) Which of the following is a potential complication of a vaginal birth after cesarean
(VBAC)?
A. Uterine rupture
B. Postpartum hemorrhage
C. Maternal infection

D. All of the above
Answer: A. Uterine rupture
Postpartum:
167) What is the recommended method of feeding for a newborn with phenylketonuria
(PKU)?
A. Breastfeeding
B. Formula feeding
C. Low phenylalanine formula feeding
D. All of the above
Answer: C. Low phenylalanine formula feeding
168) Which of the following is a potential complication of neonatal hypocalcaemia?
A. Hyperglycemia
B. Hypoglycemia
C. Hypotension
D. All of the above
Answer: C. Hypotension
Professional Practice:
169) Which of the following is a potential benefit of evidence-based practice in maternal and
newborn healthcare?
A. Improved patient outcomes
B. Increased patient satisfaction
C. Decreased healthcare costs
D. All of the above
Answer: D. All of the above
170) Which of the following is a potential barrier to evidence-based practice in maternal and
newborn healthcare?
A. Lack of access to up-to-date research
B. Resistance to change

C. Limited resources
D. All of the above
Answer: D. All of the above
171) Which of the following is a potential ethical issue related to maternal request for
caesarean delivery?
A. Autonomy versus beneficence
B. Allocation of resources
C. Informed consent
D. All of the above
Answer: A. Autonomy versus beneficence
172) Which of the following is a professional standard for nursing practice in maternal and
newborn healthcare?
A. Quality improvement
B. Patient-centered care
C. Safety
D. All of the above
Answer: D. All of the above
173) Which of the following is a potential legal issue related to maternal and newborn
healthcare?
A. Informed consent
B. Patient confidentiality
C. Child custody and visitation
D. All of the above
Answer: D. All of the above Anatomy and
Physiology:
174) Which of the following hormones stimulates ovulation?
A. Progesterone
B. Estrogen
C. Luteinizing hormone (LH)

D. Follicle-stimulating hormone (FSH)
Answer: C. Luteinizing hormone (LH)
175) What is the function of the amniotic fluid during fetal development?
A. To cushion and protect the fetus from trauma
B. To provide a medium for fetal movement and growth
C. To regulate fetal temperature
D. All of the above
Answer: D. All of the above
176) Which of the following is a potential cause of female infertility?
A. Polycystic ovary syndrome (PCOS)
B. Endometriosis
C. Pelvic inflammatory disease (PID)
D. All of the above
Answer: D. All of the above
177) A nurse is assessing the newborn of a client who took a selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse
identify as an indication of withdrawal from an SSRI?
Answer: Vomiting
Rationale:
Expected clinical manifestations associated with fetal exposure to SSRIs include irritability,
agitation, tremors, diarrhea, & vomiting. These usually last 2 days.
178) A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Answer: Remove all clothing from the newborn except the diaper.
Rationale:
The nurse should remove all of the newborn’s clothing except the diaper while under
phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the
excess bilirubin.

179) A nurse is creating a plan of care for a client who is postpartum and adheres to
traditional Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
Answer: Protect the client’s head and feet from cold air.
Rationale:
Protecting the client’s head and feet from cold air should be included in the plan of care
because this is a traditional
Hispanic practice during the postpartum period. Hispanic practices also include delaying
bathing for 14 days, bed rest for 3 days, and drinking warm beverages following delivery.
180) A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal monitoring?
Answer: Perform Leopold maneuvers.
Rationale:
The nurse should perform Leopold maneuvers to assess the position of the fetus to best
determine the optimal placement for the external fetal monitoring transducer
181) A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of
the following assessments is the nurse’s priority?
Answer: Amount of lochia
Rationale:
When using the airway, breathing, circulation approach to client care, the nurse should place
the priority in the immediate postpartum period on assessing the amount of postpartum
lochia. The greatest risk to the client is bleeding and postpartum hemorrhage.
182) A nurse is caring for a client who is in labor and whose fetus is in the right occiput
posterior position. The client is dilated to 8 cm and reports back pain. Which of the following
actions should the nurse take?
Answer: Apply sacral counterpressure
Rationale:
Sacral counterpressure assists in relieving back labor pain related to fetal posterior position.
183) A nurse is demonstrating to a client how to bathe her newborn. In which order should
the nurse perform the following actions?

Answer: Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck
by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump.
Wash the newborn’s legs and feet. Clean the newborn’s diaper area.
Rationale:
Use a head to toe, clean to dirty approach when washing a newborn.
184) A nurse is caring for a client and her partner who have experienced a fetal death. Which
of the following actions should the nurse take?
Answer: Take photos of the newborn to give to the parents.
Rationale:
The nurse should create a memory box that includes mementos of the newborn (ex: photos,
the newborn’s ID bands, the newborn’s hat, & the newborn’s blanket).
185) A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of the following
diagnostic tests?
Answer: Biophysical profile
Rationale:
A positive contraction stress test indicates that further evaluation of the fetus is necessary
(baby’s heart slowed or showed abnormality during contraction). A biophysical profile will
provide further evaluation with real-time ultrasound.
186) A nurse is reviewing the medical record of a client who is postpartum and has
preeclampsia. Which of the following laboratory results should the nurse report to the
provider? Platelets
Answer: 50,000/mm3
Rationale:
A platelet count of 50,000/mm3 is below the expected reference range, which can indicate
disseminated intravascular coagulation. The nurse should report this result to the provider.
187) A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
Answer: Minimal arm recoil
Rationale:

The nurse should expect a newborn who was born at 26 weeks gestation to have decreased
muscular tone, or minimal arm recoil.
188) A nurse is assessing a newborn following circumcision. Which of the following findings
should the nurse identify as an indication that the newborn is experiencing pain?
Answer: Chin quivering
Rationale:
Behavioral responses to a newborn’s pain include facial expressions (ex: chin quivering,
grimacing, & furrowing of the brow).
189) A nurse on an antepartum unit is caring for 4 clients. Which of the following clients
should the nurse identify as the priority?
Answer: A client who is at 34 weeks gestation and reports epigastric pain
Rationale:
Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement,
which is an urgent finding. Therefore, the nurse should identify this client as the priority.
190) A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the
following findings is an indication for the administration of the medication?
Answer: Flaccid uterus and excessive vaginal bleeding
Rationale:
Oxytocin increases the contractility of the uterus which decreases vaginal bleeding and
promotes involution.
191) A nurse is caring for a full-term newborn immediately following birth. Which of the
following actions should the nurse take first?
Answer: Dry the newborn.
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take
immediately after delivery is to dry the newborn.
192) A nurse is performing a physical assessment of a newborn. Which of the following
clinical findings should the nurse expect?

Answer: Heart rate of 154/min, respiratory rate of 58/min, and weight of 2.6kg
Rationale:
The expected reference range for a newborn’s heart rate is 110-160/min. A healthy newborn’s
temperature ranges between 36.5-37.5C (97.7-99.5F). The expected reference range for a
newborn’s respiratory rate is 30-60/min. A newborn’s length should be between 45-55cm
(17.7-21.7in) and weight between 2.54kg (5.5-8.8lb).
193) A nurse in an Antepartal clinic is providing care for a client who is at 26 weeks
gestation. Upon reviewing the client’s medical record, which of the following findings should
the nurse report to the provider?
Answer: Fundal height measurement of 30cm
Rationale:
A fundal height measurement of 30 should be reported to the provider. Fundal height should
be measured in centimeters and should equal the number of gestational weeks +/- 2 weeks
from 18-32 weeks gestation. Therefore, a fundal height of 30 at 26 weeks is greater than
expected. 1-hour glucose tolerance test results should be less than 130-140mg/dL. Hematocrit
should be greater than 33%, and FHR should be between 110-160/min.
194) A nurse is performing a routine assessment on a client who is at 18 weeks gestation.
Which of the following findings should the nurse expect?
Answer: FHR of 152/min
Rationale:
The expected range of FHR is 110-160/min with rates at the higher end of range early in the
pregnancy (<20 weeks). Deep tendon reflexes are an indication of the balance between the
cerebral cortex and spinal cord. The nurse should expect the client’s deep tendon reflexes to
be 2+. A deep tendon reflex of 4+ indicates hyperreflexia. The normal range for urine protein
is less than 1+.
195) A nurse is teaching a client who is Rh negative about Rh0(D) immune globulin. Which
of the following statements by the client indicates an understanding of the teaching
Answer: “I will need this medication if I have an amniocentesis.”
Rationale:
Rh0(D) immune globulin is given to clients who are Rh negative following an amniocentesis
because of the potential of fetal RBCs entering the maternal circulation. Rh0(D) immune

globulin is administered at 28 weeks gestation to mothers who are Rh-negative and following
the birth of a newborn who is Rh- positive.
196) A nurse is caring for a client who is anemic at 32 weeks gestation and is in preterm
labor. The provider prescribed betamethasone 12mg IM. Which of the following outcomes
should the nurse expect?
Answer: A reduction in respiratory distress in the newborn
Rationale:
Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent
respiratory distress.
197) A nurse is teaching a client who is at 8 weeks gestation about exercise. Which of the
following instructions should the nurse include in the teaching
Answer: “You should exercise for 30 minutes each day.”
Rationale:
The nurse should instruct the client to engage in 30 minutes of moderate exercise every day
to improve muscle tone throughout her pregnancy. The client should also take her pulse every
10-15 minutes during exercise, decrease weight- bearing exercises as the pregnancy
progresses, and rest in a lateral position for 10 minutes following exercise.
198) A nurse is assessing a newborn 12 hours after birth. Which of the following
manifestations should the nurse report to the provider?
Answer: Jaundice
Rationale:
Jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility,
hemolysis, or Rh- isoimmunization. Acrocyanosis is a bluish discoloration of the hands and
feet and is expected in a newborn 12 hours after birth. Transient strabismus is a normal
variation in the newborn’s eyes that can persist until 4 months of age. Caput succedaneum is
a benign edematous area of the scalp that is commonly found on the occiput.
199) A nurse is planning care for a client who is to undergo a nonstress test. Which of the
following actions should the nurse include in the plan of care?
Answer: Instruct the client to press the provided button each time fetal movement is
detected.

Rationale:
Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to
press the button when she detects fetal movement will ensure that the fetal movement is
noted. Massaging the abdomen does not stimulate fetal movement. The client should be
placed in a semi-Fowler’s or sitting position and tilted to the right or left to promote uterine
perfusion and prevent supine hypotension. There is no indication for the client to be NPO,
and sometimes clients are encouraged to drink liquids to promote adequate hydration.
200) A nurse is teaching a client who is at 35 weeks gestation about clinical manifestations of
potential pregnancy complications to report to the provider. Which of the following
manifestations should the nurse include?
Answer: Headache that is unrelieved by analgesia
Rationale:
A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported.
201) A nurse is planning care for a client who is in labor and is to have an amniotomy. Which
of the following assessments should the nurse identify as the priority?
Answer: Temperature
Rationale:
The greatest risk for a client following amniotomy is infection. Temperature is the greatest
indication of infection and should be the priority assessment.
202) A nurse is teaching a newly licensed nurse about collecting a specimen for the universal
newborn screening. Which of the following statements should the nurse include in the
teaching?
Answer: “Ensure that the newborn has been receiving feedings for 24 hours prior to
obtaining the specimen.”
Rationale:
The nurse should ensure that the newborn has been receiving regular feedings for at least 24
hours prior to testing. The universal newborn screening is mandated by law for all newborns.
Therefore, informed consent is not needed or required. The test requires the nurse to collect a
capillary blood sample via heel stick. Premature newborns have a delayed development of
liver enzymes which can cause a false positive result.

203) A client who is at 34 weeks gestation asks the nurse how she will know when she is in
labor and should go to the hospital. Which of the following responses should the nurse make?
Answer: “You will notice blood-tinged discharge from your vagina.”
Rationale:
The nurse should inform the client that a sign of true labor is the bloody show, which is a
blood-tinged discharge from the vagina that occurs when the cervix begins to efface and
dilate. This is an indication that the client should go to the hospital.
204) A nurse is caring for a client who is at 35 weeks gestation and is undergoing a nonstress
test that reveals a variable deceleration in the FHR. Which of the following actions should the
nurse take?
Answer: Have the client change positions.
Rationale:
Having the client change positions is the first intervention for a variable deceleration to
relieve umbilical cord compression.
205) A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced
abortion. The staff nurse informs the nurse manager that she has a moral issue with the
client’s decision. Which of the following actions should the nurse manager take?
Answer: Reassign the client to another staff nurse.
Rationale:
The nurse manager should take into account the staff nurse’s moral beliefs and recognize that
she also has rights and responsibilities concerning the care of a client who is undergoing an
induced abortion.
206) A nurse in the antepartum clinic is assessing a client’s adaptation to pregnancy. The
client states that she is, “happy one minute and crying the next.” The nurse should interpret
the client’s statement as an indication of which of the following?
Answer: Emotional lability
Rationale:
The nurse should recognize and interpret the client’s statement as an indication of emotional
lability. Many women experience rapid and unpredictable changes in mood during pregnancy.
Intense hormonal changes may be responsible for mood changes that occur during pregnancy.
Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. The

focusing phase is the third phase of the father’s emotional response to the pregnancy. It is
characterized by his active involvement in the pregnancy and his relationship with the child.
Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the
woman’s life. The degree of acceptance is shown in the mother’s emotional responses.
Couvade syndrome is pregnancy-life manifestations experienced by the expectant father.
Manifestations may include nausea, weight gain, and other physical manifestations of
pregnancy.
207) A nurse is teaching a client who is at 10 weeks gestation about nutrition during
pregnancy. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: :I should take 600 micrograms of folic acid each day.”
Rationale:
A client who is pregnant should increase her folic acid intake to 600mcg daily. Folic acid
assists with preventing neural tube birth defects. A client who is pregnant should also increase
her protein intake to 71g daily, water intake to 3L daily, increase her caloric intake by 340
during the second trimester, and by 452 during the third trimester.
208) A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of
the following actions should the nurse take?
Answer: Schedule an ultrasound examination.
Rationale:
The nurse should schedule serial ultrasound examinations to monitor the fetus during the
pregnancy to detect the possible development of fetal hydrops.
209) A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to
perform Leopold maneuvers. Which of the following images indicates the first step of
Leopold maneuvers?
Answer:

Rationale:
The first step of Leopold’s maneuvers is to palpate the abdomen with the palms to determine
which fetal part is in the uterine fundus.
210) A nurse is caring for a client who is pregnant and is at the end of her first trimester. The
nurse should place the Doppler ultrasound stethoscope in which of the following locations to
begin assessing for the fetal heart tones (FHT)?
Answer: Just above the symphysis pubis
Rationale:
At the end of the first trimester of pregnancy, the client’s uterus is approximately the size of a
grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore,
the nurse should assess for FHTs just above that.
211) A nurse is preparing to administer hepatitis B immune globulin to a newborn. The
prescription states, “Administer 5 mcg IM once today.” Available is a 5 mL vial with 10
mcg/mL. How many mL should the nurse administer (rounded to the nearest tenth)?
Answer: 0.5 mL
212) A nurse is assessing a client who is in labor and notes early decelerations on the fetal
monitor. Which of the following findings should the nurse identify as a possible cause of the
early decelerations?
Answer: Fetal head compression
Rationale:

The nurse should identify that early decelerations are an expected fetal pattern caused by fetal
head compression due to uterine contractions, fundal pressure, and vaginal examinations.
213) A nurse is providing teaching about family planning to a client who has a new
prescription for a diaphragm. Which of the following statements should the nurse include in
the teaching?
Answer: “You should leave the diaphragm in place for at least 6 hours after intercourse.”
Rationale:
The client should be advised that the diaphragm must remain in place for at least 6 hours after
intercourse to provide the most protection against pregnancy. The diaphragm should be
replaced every 2 years. The client should have an empty bladder prior to insertion and avoid
using oil- based products because they weaken the rubber of the diaphragm.
214) A nurse is caring for a client who is 36 weeks gestation and has a prescription for an
amniocentesis. For which of the following reasons should the nurse prepare the client for an
ultrasound?
Answer: To locate a pocket of fluid
Rationale:
Locating a pocket of fluid using the ultrasound prior to the amniocentesis reduces the risk of
injury to the fetus.
215) A nurse is caring for a client who becomes unresponsive upon delivery of the placenta.
Which of the following actions should the nurse take first?
Answer: Determine respiratory function.
Rationale:
The priority using the airway, breathing, circulation approach is to determine the respiratory
function and the need for cardiopulmonary resuscitation.
216) A nurse is teaching a client who is pregnant about managing nausea and vomiting.
Which of the following instructions should the nurse include in the teaching?
Answer: “Eat high carbohydrate foods.”
Rationale:

The nurse should instruct the client to eat high carbohydrate foods such as toast, potatoes, and
rice to decrease nausea and vomiting. The client should also be instructed to avoid spicy,
fatty, or fried foods.
217) A nurse is calculating a client’s expected date of birth using Naegele’s rule. The client
tells the nurse that her last menstrual cycle started on November 27th. Which of the following
dates is the clients expected date of birth?
Answer: September 3rd
Rationale:
Naegele’s rule = first day of last cycle – 3 months + 7 days
218) A nurse is observing a new mother caring for her crying newborn who is bottle feeding.
Which of the following actions by the mother should the nurse recognize as positive
parenting behavior?
Answer: Lays the newborn across her lap and gently sways
Rationale:
This tactile stimulation promotes a sense of security for the new born and is a correct
technique for quieting a newborn.
219) A nurse is teaching a client who is in preterm labor about terbutaline. Which of the
following statements by the client indicates an understanding of the teaching?
Answer: “I will have blood tests because my potassium might decrease.”
Rationale:
Terbutaline is administered subcutaneously every 4 hours for no longer than 24 hours. The
adverse effects are hyperglycemia, hypokalemia, and hypotension.
220) A nurse is reviewing the laboratory report of a client who is 24 hours postpartum
following a vaginal delivery. Which of the following laboratory results should the nurse
identify as an indication of a postpartum infection?
Answer: Erythrocyte Sedimentation Rate (ESR) 26 mm/hr
Rationale:
The nurse should recognize that this exceeds the expected reference range for a postpartum
client and indicates infection.

221) A nurse is planning discharge for a client who is 3 days postpartum. Which of the
following nonpharmacological interventions should the nurse include in the plan of care for
lactation suppression?
Answer: Apply cabbage leaves to the breasts
Rationale:
Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort
caused by breast engorgement
222) A nurse is caring for a client following an amniocentesis at 18 weeks gestation. Which
of the following findings should the nurse report to the provider as a potential complication?
Answer: Leakage of fluid from the vagina
Rationale:
Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and
should be reported to the provider.
223) A nurse is teaching a new mother about newborn safety. Which of the following
instructions should the nurse include in the teaching?
Answer: “You can share your room with your baby for the next few weeks.”
Rationale:
Room-sharing is recommended during the first few weeks. This allows the parents to be
readily available to the newborn and learn the newborn’s cues. However, the nurse should
instruct the parents to avoid placing the newborn in their bed as it increases the risk for SIDS.
224) A nurse is assessing a client who is at 30 weeks gestation during a routine prenatal visit.
Which of the following findings should the nurse report to the provider?
Answer: Swelling of the face
Rationale:
Swelling of the face, sacral area, and hands can indicate gestational HTN or preeclampsia.
Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the
intravascular compartment into the tissues, causing edema. Varicose veins in the calves,
nonpitting 1+ ankle edema, and hyperpigmentation of the cheeks are expected findings in the
third trimester.

225) A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid
replacement. Which of the following findings should the nurse report to the provider?
Answer: BUN 25mg/dL
Rationale:
The nurse should report an elevated BUN to the provider since it can indicate dehydration.
226) A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients
should the nurse request the provider see first?
Answer: A client who is at 11 weeks gestation and reports abdominal cramping
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a client who is at 11 weeks gestation and reports abdominal cramping.
Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous
abortion. The nurse should request that the provider see this client first.
227) A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her
uterus to the right above the umbilicus. Which of the following interventions should the nurse
perform?
Answer: Assist the client to empty her bladder.
Rationale:
The nurse should assist the client to empty her bladder because the assessment findings
indicate that the bladder is distended. This can prevent the uterus from contracting, resulting
in increased vaginal bleeding or postpartum hemorrhage. Simethicone should be administered
to reduce bloating, discomfort, or pain caused by excessive gas.
228) A nurse is caring for a postpartum client who is receiving heparin via a continuous IV
infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse
take?
Answer: Maintain the client on bed rest.
Rationale:
The client should remain on bed rest to decrease the risk of dislodging the clot, which could
cause a pulmonary embolism. A client receiving anticoagulant therapy, such as heparin,
should not receive aspirin due to the risk of bleeding. The nurse should avoid massaging the
affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary

embolism. The nurse should apply warm compresses to the affected area to promote
circulation and decrease edema.
229) A nurse is providing teaching about comfort measures to a client who is breastfeeding
and is experiencing engorgement. Which of the following nonpharmacological measures
should the nurse include in the teaching?
Answer: “You should use cold compresses after each feeding.”
Rationale:
The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts
of engorgement in the client who is breastfeeding. The client should avoid the use of breast
binders because they can decrease the milk supply. Applying colostrum to the nipples helps
with sore nipples, and breast shells may be worn to promote circulation of air and prevent
clothing from touching sore nipples.
230) A nurse is teaching a new mother about steps the nurses will take to promote the security
and safety of the newborn. Which of the following statements should the nurse make?
Answer: “Staff members who take care of your baby will be wearing a photo identification
badge.”
Rationale:
The nurse should teach the client that all staff members that care for newborns are required to
wear a photo identification badge so that the client will be reassured of her newborn’s safety.
When entering the unit, visitors must only provide the name of the client they are visiting.
Clients are allowed to have anyone visit them on the unit without documentation of the
visitor’s relationship to the client. The nurse should teach the mother to place the baby in the
bassinet on the side of the bed away from the door while she is sleeping.
231) A nurse is assessing a late preterm newborn. Which of the following clinical
manifestations is an indication of hypoglycemia?
Answer: Respiratory distress
Rationale:
Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen
stores and immature insulin secretion. Respiratory distress is a clinical manifestation of
hypoglycemia. Other manifestations include an abnormal cry, jitteriness, lethargy, poor
feeding, apnea, and seizures.

232) A nurse is providing teaching to a client about the physiological changes that occur
during pregnancy. The client is at 10 weeks gestation and has a BMI within the expected
reference range. Which of the following client statements indicates an understanding of the
teaching?
Answer: “I will likely need to use alternative positions for sexual intercourse.”
Rationale:
The weight gain of pregnancy will likely require alternative positions for sexual intercourse.
The recommended weight gain for a woman with a normal BMI is 2535lbs. The
recommended weight gain for a woman who has a BMI above the expected range is 15-20lbs.
233) A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum.
Which of the following information should the nurse include?
Answer: “Your newborn should appear content after each feeding.”
Rationale:
A baby who continues to show indications of hunger such as rooting, sucking on the hands, or
crying may not be effectively emptying the breasts during feedings. The client’s breasts
should feel softer after feeding indicating that they were emptied during the session. Mature
milk production occurs 3- 4 days postpartum. The newborn should void 6-8 times per day
with at least 3 stools per day. It is not uncommon for a breastfed newborn to have stools with
each feeding.
234) A nurse is teaching a client who is 36 weeks gestation and has a prescription for a
nonstress test. Which of the following statements should the nurse include in the teaching?
Answer: “You will be offered orange juice to drink during the test.”
Rationale:
Having the client drink orange juice or another beverage high in glucose will stimulate the
fetus during the procedure, helping to obtain results of fetal activity. The procedure will take
20-40 minutes and is non-invasive. Non-invasive procedures do not require informed
consent.
235) A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia
pupura (ITP). Which of the following findings should the nurse suspect?
Answer: Decreased platelet count

Rationale:
A client who has ITP has an autoimmune response that results in a decreased platelet count.
An increased ESR is an indication of chronic renal failure, and increased WBCs is an
indication of infection.
236) A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client’s history should the nurse
recognize as a contraindication to oral contraceptives?
Answer: Cholecystitis, HTN, and migraine headaches
Rationale:
A history of gallbladder disease (cholecystitis), HTN, or migraines are all contraindications
for oral contraceptives.
237) A nurse is teaching a new mother how to use a bulb syringe to suction her newborn’s
secretions. Which of the following instructions should the nurse include?
Answer: Stop suctioning when the newborn’s cry sounds clear.
Rationale:
The client should stop suctioning when the newborn’s cry no longer sounds like it is coming
through a bubble of fluid or mucus. The client should compress the bulb before inserting the
syringe tip to avoid pushing/blowing the secretions further inside. The newborn’s mouth
should always be suctioned before the nose (Nobody wants to taste their own snot!), and the
syringe should be inserted into the side of the mouth to avoid triggering the gag reflex.
238) A nurse is assessing a client who is in active labor and notes early decelerations in the
FHR on the monitor tracing. The client is 39 weeks gestation and is receiving a continuous IV
infusion of oxytocin. Which of the following actions should the nurse take?
Answer: Continue monitoring the client.
Rationale:
Early decelerations in the FHR are considered benign and occur due to compression of the
fetal head during contractions, vaginal exams, and pushing during the second stage of labor.
No interventions are necessary for early decelerations.
239) A nurse is teaching a group of parents about newborn safety. Which of the following
statements by a parent indicates an understanding of the teaching?

Answer: “I will dress my baby in flame-retardant clothing.”
Rationale:
Flame-retardant clothing will help prevent injury to the baby. Parents should avoid using
plastic in the crib or bibs around the newborn’s neck at night to avoid suffocation and
choking. The parents should not heat formula in a microwave to prevent uneven warming.
240) A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma.
Which of the following manifestations should the nurse expect?
Answer: Vaginal pressure
Rationale:
The nurse should expect a client with a vaginal hematoma to report pressure in the vagina due
to the blood that leaked into the tissues and persistent vaginal or rectal pain. Lochia serosa
vaginal drainage is a manifestation for a client who is 4-10 days postpartum.
241) A charge nurse on the postpartum unit is observing a newly licensed nurse who is
preparing to administer pain medication to a client. The charge nurse should intervene when
the newly licensed nurse uses which of the following secondary identifiers to identify the
client?
Answer: The client’s room number
Rationale:
The client’s room number can change and places the client at risk for a medication error.
242) A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago.
Which of the following instructions should the nurse include
Answer: “You can still become pregnant if you are breastfeeding.”
Rationale:
The nurse should inform the client that breastfeeding does not prevent ovulation.
Contraception that is safe during breastfeeding should be discussed with this client. It is
recommended that the client wait until after the 6- week follow-up appointment to resume
sexual activity. Kegel exercises are helpful to maintain tone of the pelvic muscles and ensure
future urinary continence after any pregnancy. The client should avoid abdominal exercises
for 4-6 weeks following a cesarean birth.

243) A nurse is providing discharge teaching to a client who is postpartum. For which of the
following clinical manifestations should the nurse instruct the client to monitor and report to
the provider?
Answer: Unilateral breast pain
Rationale:
Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of
the breast tissue that should be reported to the provider. Persistent abdominal striae are
caused by the separation of the underlying connective tissue and are an expected postpartum
finding. Temperatures of 100.4F or higher should be reported as an indication of infection.
Brownish-red discharge is an expected manifestation for 3-10 days postpartum. The client
should report a large amount of lochia or clots to the provider.
244) A nurse is caring for a client who is 15 weeks gestation, Rh- negative, and has just had
an amniocentesis. Which of the following interventions is the nurse’s priority following the
procedure?
Answer: Monitor the FHR
Rationale:
The greatest risk to this client and her fetus is fetal death.
245) A nurse is admitting a client to the labor and delivery unit when the client states, “My
water just broke.” Which of the following interventions is the nurse’s priority?
Answer: Begin FHR monitoring.
Rationale:
The greatest risk to the client and her fetus following a rupture of membranes is umbilical
cord prolapse. The nurse should monitor the fetus closely to ensure well-being.
246) A nurse is caring for a client who has recently experienced a perinatal death. Which of
the following statements should the nurse make to the client?
Answer: “I’m sad for you.”
Rationale:
This statement shows empathy and encourages the client to communicate about the death.
247) A nurse is assessing a client who is 38 weeks gestation during a weekly prenatal visit.
Which of the following findings should the nurse report to the provider?

Answer: Weight gain of 2.2kg (4.8lb)
Rationale:
This is greater than the expected weekly weight gain and could indicate complications.
248) A nurse is caring for a client who has uterine hypotonicity and is experiencing
postpartum hemorrhage. Which of the following actions is the nurse’s priority?
Answer: Massage the client’s fundus.
Rationale:
The nurse’s priority is to massage the client’s fundus to minimize blood loss and help prevent
hypovolemic shock.
249) A nurse in a provider’s office is reviewing the medical record of a client who is in her
first trimester. Which of the following findings should the nurse identify as a risk factor for
the development of preeclampsia?
Answer: Pregestational diabetes
Rationale:
Risk factors for the development of preeclampsia include pregestational diabetes, preexisting
HTN, renal disease, systemic lupus erythematosus, BMI greater than 30, multifetal
gestations, maternal age less than 19 or greater than 40, and rheumatoid arthritis.
250) A nurse is planning care for a client who is in labor and is requesting epidural anesthesia
for pain control. Which of the following actions should the nurse include in the plan of care?
Answer: Monitor the client’s blood pressure every 5 minutes following the first dose of
anesthetic solution.
Rationale:
The nurse should plan to obtain a baseline blood pressure prior to the initial dose of
anesthetic solution and monitor every 5-10 minutes after to assess for maternal hypotension.
The nurse should also plan to position the client upright to allow the solution to flow
downward, administer 500-1000mL of lactated Ringer’s or normal saline 15-30 minutes prior
to the first dose in order to reduce the risk of maternal hypotension. Dextrose should not be
administered because it can cause maternal hyperglycemia and fetal hypoglycemia.

251) A nurse is providing teaching about nonpharmacological pain management to a client
who is breastfeeding and has engorgement. The nurse should recommend the application of
which of the following items?
Answer: Cold cabbage leaves
252) A nurse is providing prenatal teaching to a client who is 26 weeks gestation. Which of
the following positions should the nurse recommend for the client to increase circulation to
the placenta?
Answer: Side-lying
Rationale:
Side-lying avoids compression of the vena cava and promotes placental perfusion.
253) A nurse is speaking with a client who is trying to make a decision about uterine tube
occlusion. The client asks, “What effects will this procedure have on my sex life?” Which of
the following responses should the nurse make?
Answer: “This process should have no effect on your sexual performance or adequacy.”
Rationale:
Sexual function depends on various hormonal and psychological factors. Tubal occlusion
should have no physiological effect on sexual performance or adequacy. Enjoyment of sex
should increase due to the loss of fear of pregnancy.
254) A nurse is discussing the differences between true labor and false labor with a group of
expectant parents. Which of the following characteristics should the nurse include when
discussing true labor?
Answer: Contractions become stronger with walking
Rationale:
The contractions that occur during true labor increase in intensity and become more regular
with a change in activity. True labor cannot be suppressed by using comfort measures, and
the pain is felt in the lower back and lower abdomen.
255) A nurse is teaching a client who has pregestational type 1 diabetes about management
during pregnancy. Which of the following statements by the client indicates an understanding
of the teaching?
Answer: :I will continue taking my insulin if I experience nausea and vomiting.”

Rationale:
The client should continue taking her insulin as prescribed during illness to prevent
hypoglycemia and hyperglycemia. Her fasting glucose goal should be 6090mg/dL. The nurse
should teach the client to avoid snacks and foods high in refined sugar and to not exercise
during periods of hyperglycemia and when positive urine ketones are present.
256) A nurse is assessing a newborn who was delivered vaginally and experienced a tight
nuchal cord. Which of the following clinical manifestations should the nurse expect?
Answer: Petechiae over the head
Rationale:
Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising
and petechiae over the face, head, and neck.
257) A nurse is teaching a client who is 24 weeks gestation regarding 1- hour glucose
tolerance testing. Which of the following statements should the nurse include in her teaching?
Answer: “A blood glucose of 130-140 is considered a positive screening result.”
Rationale:
The nurse should teach the client that a blood glucose level of 130-140 is considered a
positive screening. If she receives a positive result, she will need to undergo a 3-hour glucose
tolerance test to confirm gestational diabetes.
258) A nurse is assessing a newborn who is 12 hours old. Which of the following clinical
manifestations requires intervention by the nurse?
Answer: Substernal chest retractions while sleeping
Rationale:
Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This
clinical manifestation requires further assessment and intervention by the nurse. An audible
murmur at the left sternal border is an expected finding in newborns. Acrocyanosis is a bluish
discoloration of the newborn’s hands and feet and is expected. Babinski reflex is a normal
finding that is elicited when a newborn’s sole is stroked and the newborn’s toes hyperextend
in response.

259) A nurse is caring for a client who is 22 weeks gestation and reports concern about the
blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse
take?
Answer: Explain to the client that this is an expected occurrence.
Rationale:
Chloasma, the mask of pregnancy, is a blotchy brown hyperpigmentation of the skin over the
cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an
increase in melanotropin during pregnancy. It appears after 16 weeks gestation and increases
gradually until deliver for 50- 70% of women. The nurse should reassure the client that this is
expected and usually fades after delivery.
260) A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of
the following findings contraindicates the initiation of the oxytocin infusion and should be
reported to the provider?
Answer: Late decelerations
Rationale:
Late decelerations are indicative of uteroplacental insufficiency and is a contraindication for
the administration of oxytocin.
261) A nurse is planning care for a client who is 24 weeks gestation and reports daily mild
headaches. Which of the following instructions should the nurse include in the plan of care?
Answer: Recommend that the client perform conscious relaxation techniques daily.
Rationale:
Conscious relaxation techniques are a way to relieve tension and reduce stress which can help
to decrease and eliminate headaches.
262) A nurse is providing discharge teaching to a parent whose newborn has just had a
circumcision. Which of the following instructions should the nurse include?
Answer: Apply slight pressure with a sterile gauze pad for mild bleeding.
Rationale:
The client should attempt to stop mild bleeding first with a sterile gauze pad, and if
unsuccessful, the client should notify the provider. The client should change the newborn’s
diaper and examine the circumcision site at least every 4 hours. Baby wipes containing
alcohol can irritate the skin and should be avoided until the circumcision has healed, which

usually takes 5-6 days. During each diaper change, the penis should be washed gently with
warm water and have petroleum jelly applied to the glans. The client should not attempt to
remove any yellow exude from the circumcision site because it is part of the healing process,
which begins 24 hours post procedure and can last 2-3 days. Disrupting this process can
cause pain and bleeding.
263) A nurse is reviewing the medical record at 1800 for a client who is 34 weeks gestation.
Based on the chart findings and documentation, the nursing plan of care should include which
of the following actions?
Answer: Administer terbutaline.
Rationale:
The nurse should administer terbutaline to stop contractions because the lab results indicate
that the fetus’s lungs are not mature enough for delivery.
264) A nurse is developing a plan of care for a client who has preeclampsia and is receiving
magnesium sulfate via a continuous IV infusion. Which of the following interventions should
the nurse include in the plan?
Answer: Monitor FHR continuously.
Rationale:
Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a
high-alert medication that requires close monitoring. The FHR and uterine contractions
should be monitored continuously while the client is treated with this medication. The vitals
should be monitored every 15- 30 minutes. Intake should be no more than 125mL/hr.
Calcium gluconate should only be administered if the client shows signs of magnesium
sulfate toxicity such as loss of deep tendon reflexes, respiratory depression, slurred speech, or
cardiac arrest.
265) A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in
preterm labor. Available is 20g magnesium sulfate in 500mL dextrose 5% in water (D5W).
The nurse should set the IV infusion pump to administer how many mL/hr? (Whole number)
Answer: 50mL/hr

266) A nurse in a woman’s health clinic is providing teaching about nutritional intake to a
client who is 8 weeks gestation. The nurse should instruct the client to increase her daily
intake of which of the following nutrients?
Answer: Iron
Rationale:
The recommendation for iron intake during pregnancy is 27mg/day.
267) A nurse is teaching clients in a prenatal class about the importance of taking folic acid
during pregnancy. The nurse should instruct the clients to consume an adequate amount of
folic acid from various sources to prevent which of the following fetal abnormalities?
Answer: Neural tube defect
Rationale:
The nurse should inform the clients that neural tube defects are more common in newborns
born to mothers who had inadequate folic acid intake. Food sources of folic acid include
fortified cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.
268) A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which
of the following findings is an adverse effect of this medication?
Answer: Hypertension
Rationale:
The nurse should recognize that carboprost is a vasoconstrictor that can cause HTN.
269) A nurse is caring for a newborn who is undergoing phototherapy to treat
hyperbilirubinemia. Which of the following actions should the nurse take?
Answer: Cover the newborn’s eyes while under the phototherapy light.
Rationale:
Applying an opaque eye mask prevents damage to the newborn’s retinas and corneas from the
phototherapy light. All of the newborn’s clothing should be removed except a diaper when
undergoing phototherapy. All moisture or creams should be avoided because they can absorb
heat and cause burns. The nurse should turn and reposition the newborn every 2-3 hours to
allow for maximum exposure of body surfaces to the phototherapy light.
270) A nurse is performing a newborn assessment. Which of the following images should the
nurse identify as an indication of spina bifida occulta?

Answer:

Rationale:
External indications of the neural tube defect spina bifida occulta include a dimpled area over
the defect and the presence of a birthmark or hairy patch above the area.
271) A nurse is providing teaching for a client who gave birth 2 hours ago about the facility
policy for newborn safety. Which of the following client statements indicate an understanding
of the teaching?
Answer: “The person who comes to take my baby’s pictures will be wearing a photo
identification badge.”
Rationale:
All personnel working on the unit should wear a photo identification badge. The nurse should
teach the mother to never allow anyone who is not wearing an identification badge to come in
contact with her newborn. The nurse will match the newborn’s identification number with the
mother’s when she brings the baby to the mother’s room. Newborns should always be
transported in a bassinet when outside the mother’s room and should always wear the
electronic security bracelet because it will alarm if anyone removes it or if the infant is
brought near an exit door.
272) A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence
the nurse should follow.
Answer: Palpate the fundus to identify the fetal part. Determine the location of the fetal back.
Palpate for the fetal part presenting at the inlet.

Identify the attitude of the head.
273) A nurse is assessing a full-term newborn 15 minutes after birth. Which of the following
findings requires intervention by the nurse?
Answer: Respiratory rate 18/min
Rationale:
During the first phase of a newborn’s transition, up to 30 minutes after birth, the respiratory
rate can range 20- 100/min, heart rate of 160-180, presence of tremors, crying, and startling
motions, and fine crackles and nasal flaring are expected.
274) A nurse is caring for a client who is 40 weeks gestation and in early labor. The client has
a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment
modalities should the nurse anticipate?
Answer: Attention-focusing
Rationale:
• The low platelet count places the client at a high risk for bleeding which contraindicates the
placement of an epidural. A pudendal nerve block is administered during the third stage of
labor for the repair of an episiotomy or laceration.
• Attention-focusing and distraction techniques are the safest types of care for this patient to
effectively relieve her labor pain.
275) A school nurse is providing teaching to an adolescent about levonorgestrel
contraception. Which of the following information should the nurse include in the teaching?
Answer: “You should take the medication within 72 hours following unprotected sexual
intercourse.”
Rationale:
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception.
It has no effect on the other oral contraceptive the adolescent might be taken and should be
taken if an adolescent misses a dose of her regular daily oral contraception and engages in
unprotected sex.
Levonorgestrel will not protect from future instances of unprotected sex after taking the
medication.

276) A nurse is caring for a client who is in labor and reports increasing rectal pressure. She
is experiencing contractions 2-3 minutes apart, each lasting 80-90 seconds, and a vaginal
exam reveals her cervix is dilated to 9cm. The nurse should identify that the client is in which
of the following phases of labor?
Answer: Transition
Rationale:
• Latent phase is the first phase of labor characterized by cervical dilation of 0-3cm and
contractions every 5-30 minutes each lasting 30-45 seconds. Active phase is the second phase
of labor characterized by cervical dilation of 4-7cm and contractions every 3-5 minutes each
lasting 40-70 seconds.
• Transition phase is the next phase of labor characterized by cervical dilation of 810cm and
contractions every 2-3 minutes each lasting 45-90 seconds. Descent phase is the last phase of
labor characterized by active pushing with contractions every 12 minutes each lasting 90
seconds each.
277) A nurse is performing a vaginal exam on a client who is in labor and reports severe
pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior
position. The nurse should identify that which of the following is the best
nonpharmacological intervention to perform to relieve the client’s discomfort
Answer: Counter-pressure
Rationale:
Counter-pressure is the best nonpharmacological technique to use when relieving the client’s
discomfort from the fetus being in a posterior position because this intervention lifts the fetal
head off of the spinal nerve.
278) A nurse is developing an educational program for adolescents about nutrition during the
third trimester. Which of the following statements should the nurse include in the program?
Answer: “Consume 3-4 servings of dairy each day.”
Rationale:
Calcium intake is important during an adolescent’s pregnancy because bone absorption of
calcium is still occurring. Sodium supports the increase in blood volume that occurs during
pregnancy. Adequate sodium intake is 1.5g/day. Adequate protein is necessary to support the
rapid growth of the fetus, maternal tissues, increasing blood volume, and the formation of the
amniotic fluid. Protein intake during the second and third trimester should be 71g daily.

279) A nurse is planning care for a client who is 2 hours postpartum. Which of the following
interventions should the nurse plan to implement during the taking-hold phase of postpartum
behavioral adjustment?
Answer: Demonstrate to the client how to perform a newborn bath.
Rationale:
During the taking-in phase, the client displays dependent and passive behaviors and due to
excitement and fatigue is unable to retain information. During this phase, the nurse should
repeat instructions to ensure client understanding and should allow the client and her partner
to reflect on the birth experience. During the taking-hold phase, the mother begins taking a
stronger interest in her role as mother and is focusing on the care of her newborn and
acquiring new parenting skills. This is the perfect time to teach the client caregiving skills
while offering positive reinforcement to promote maternal adjustment and confidence. The
letting-go phase focuses on moving forward as a family with interchanging members. The
discussion of contraceptive options should occur during this last phase.
280) A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which
of the following techniques should the nurse use to help minimize the pain of the procedure
for the newborn?
Answer: Place the newborn skin to skin on the mother’s chest.
Rationale:
Placing the newborn skin to skin on the mother’s chest is an effective technique to
significantly decrease the newborn’s pain and anxiety levels. The nurse should implement
this technique before, during, and after the procedure. A warm pack can also be applied prior
to the puncture to help ensure an adequate specimen is obtained.
281) A nurse is caring for a newborn who was transferred to the nursery 30 minutes after
delivery. Which of the following actions should the nurse take first?
Answer: Verify the newborn’s identification.
Rationale:
When using the safety/risk reduction approach to client care, the first action the nurse should
take is to verify the newborn’s identity upon arrival to the nursery. IM vitamin K is
administered soon after birth to increase clotting factors and prevent bleeding but can be
delayed until after initial bonding time and the first breastfeeding.

282) A nurse is performing a physical assessment of a newborn upon administration to the
nursery. Which of the following clinical manifestations should the nurse expect?
Answer: Creases over 2/3 of the soles of the feet, molding of the head, and lanugo on the
shoulders.
Rationale:
Molding of the head occurs during the birth process as the newborn travels through the birth
canal, resulting in compression of the soft bones of the skull.
283) A nurse providing dietary teaching to a client who has hyperemesis gravidarum. Which
of the following statements by the client indicates understanding of the teaching?
Answer: “I will eat foods that appeal to my taste instead of trying to balance my meals.”
Rationale:
Clients who have hyperemesis gravidarum should eat to taste to avoid nausea, avoid going to
bed with an empty stomach, alternate liquids and solids every 2-3 hours to avoid empty
stomach or over-filling, and should eat protein following a client's statement reflects an
understanding that eating foods that appeal to their taste can help reduce nausea and avoid
further irritation. Small, frequent meals help prevent an empty stomach, which can worsen
nausea. Alternating liquids and solids every 2-3 hours helps avoid overfilling or emptying the
stomach, both of which can trigger symptoms. Consuming protein after carbohydrates
stabilizes blood sugar, reducing nausea. Hydration is essential, but drinking in small sips
between meals prevents discomfort and dehydration.
284) A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has
determined the fetal position as left occipital anterior. To which of the following areas of the
client’s abdomen should the nurse apply the ultrasound transducer in order to assess the point
of maximum intensity of the fetal heart?
Answer: Left lower quadrant
Rationale:
The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left
lower quadrant. The fetal heart tones of a fetus in the left sacrum anterior position are best
heard in the left upper quadrant. The fetal heart tones of a fetus in the right sacrum anterior
position are best heard in the right upper quadrant. The fetal heart tones of a fetus in the right
occipital anterior position are best heard in the right lower quadrant.

285) A nurse is providing discharge teaching to the parents of a newborn about using a car
seat properly. Which of the following instructions should the nurse include?
Answer: Position the car seat rear-facing in the back seat of the vehicle.
Rationale:
Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or
reach the height and weight requirements of the car seat manufacturer. The newborn should
be placed at a 45 degree angle to minimize the risk of airway obstruction from leaning
forward. The retainer clip should be at the level of the newborn’s axillae and the shoulder
harness just below the newborn’s shoulders.
286) A nurse is providing education about family bonding to parents who recently adopted a
newborn. The nurse should make which of the following suggestions to aid the family’s 7
year old child in accepting the new family member?
Answer: Obtain a gift from the newborn to present to the sibling.
Rationale:
Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age
sibling’s acceptance of the new family member so that the new sibling doesn’t feel left out
and understands his role in the family.
287) A nurse is assessing 4 newborns. Which of the following findings should the nurse
report to the provider?
Answer: A newborn who is 18 hours old and has an axillary temperature of 37.7C (99.9F)
Rationale:
An axillary temperature greater than 37.5D (99.5F) is above the expected range and can be an
indication of sepsis.
Erythema toxicum is a transient rash that can occur anywhere on the newborn’s body during
the first 24-72 hours following birth but requires no intervention. Meconium stool should be
passed within the first 24-48 hours following birth. Pink tinged urine is an indication of uric
acid crystals and an expected finding in a newborn for the first week following birth.
288) A nurse is performing a vaginal exam for a client who is in active labor and reports back
pain. The nurse determines that the client is 8cm dilated, 100% effaced, -2 station, and that

the fetus is in the occiput posterior position. Which of the following actions should the nurse
take?
Answer: Assist the client to the hands and knees position.
Rationale:
The nurse should assist the client into the hands and knees position to help relieve the back
pain and enable the rotation of the fetus from the posterior to an anterior occiput position.
289) A nurse is assessing a client who is 12 hours postpartum. The client’s fundus is 2
fingerbreadths above the umbilicus, deviated to the right of midline, and less firm than
previously noted. Which of the following actions should the nurse take?
Answer: Assist the client to the bathroom to void.
Rationale:
A distended bladder inhibits the uterus from contracting normally and can cause uterine
atony.
290) A nurse is assessing a client who is 26 weeks gestation. Which of the following
manifestations should the nurse report to the provider?
Answer: Decreased urine output
Rationale:
Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can
be signs of preeclampsia and should be reported.
291) A nurse in a maternal-newborn unit is assisting in the care of a newborn in the nursery.
The newborn's grandparent asks if they may take the newborn to their daughter's room.
Which of the following responses should the nurse make?
Answer: "Let me wash my hands and then I'll take the baby to their mother."
292) A nurse is assisting in the care of a newborn who has a high-pitched cry and does not
respond to consoling efforts. Which of the following neonatal data collection tools should the
nurse expect to complete?
Answer: Neonatal Abstinence Scoring System

293) A nurse is reinforcing teaching about newborn umbilical cord care with a client who is
postpartum. Which of the following statements should the nurse identify as an indication that
the client understands the instructions?
Answer: "I will report any drainage from my baby's umbilical cord."
294) A nurse on a postpartum unit is assisting in the care of a client who is experiencing
hypovolemic shock. Which of the following actions should the nurse take?
Answer: Insert an indwelling urinary catheter
295) A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine
hypotension with a client who is at 16 weeks of gestation. Which of the following responses
by the client indicates an understanding of the teaching?
Answer: "I will lie on my left side with my head elevated on a pillow."
296) A nurse is assisting in the care of a newborn who is large for gestational age and is
jittery. Which of the following actions should the nurse take first?
Answer: Check the newborn's blood glucose level
297) A nurse is assisting with the care of a client who is at 39 weeks of gestation. Which of
the following statements should alert the nurse as a sign of a potential complication?
Answer: "I have pain in my upper right abdomen."
298) A nurse is planning to perform a blood collection via heel stick on a newborn. After
performing hand hygiene and donning gloves, which of the following actions should the
nurse plan to take next?
Answer: Wrap the newborn's heel with a cloth moistened with warm water
299) A nurse is reinforcing teaching about newborn home safety precautions with a group of
parents. Which of the following instructions should the nurse include?
Answer: "You should ensure that crib slats are no more than 2.25 inches apart" A
300) A nurse is monitoring a 1-hr-old newborn for hypoglycemia. For which of the following
findings should the nurse monitor? (Select all that apply)
Answer: Hypothermia Twitching Tachypnea

301) A nurse is reinforcing teaching about car seat safety with the guardian of a newborn.
Which of the following client statements indicates an understanding of the teaching?
Answer: "If my baby rides in a car with no back seat, the passenger air bag must be turned
off."
302) A nurse on an antepartum unit is assisting in the care for a client
Answer: • Insert a large-bore intravenous catheter-indicated
• Request a prescription for methotrexate-contraindicated
• Position client for assessment of cervical dilation by RN-contraindicated
• Obtain blood specimen for an hog level-nonessential
• Weigh perineal pads-indicated
303) A nurse is assisting in the care of a client who is in labor. The client's assessment and
documentation are performed by the RN
Answer: • Place the client in Trendelenburg position
• Provide oxygen at 8 to 10 L/min via non breather mask
• Wrap the cord in warm, sterile, saline compresses
304) A nurse is caring for a client who is at 32 weeks gestation and has a prescription for
nifedipine. Which of the following outcomes should the nurse expect from this medication?
Answer: Cessation of uterine contraction
305) A nurse is assisting in the care of a client during the active phase of labor. Which of the
following actions should the nurse take to promote the client's comfort?
Answer: Have the client perform relaxing breathing techniques
306) A nurse is assisting in the care of a newborn. Which of the following actions should the
nurse plan implement?
Answer: • Remind the parents to begin range-of-motion (ROM) exercises on the affected
arm after 1 week-indicated
• Secure padding in the newborn's fist on the affected side-nonessential
• Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirtindicated

• Reinforce to parents to limit physical handling for 2 weeks-contraindicated
• Monitor extremity for edema-nonessential
307) A nurse is assisting in the care of a client who is planning to become pregnant. The
client asks the nurse why folic acid supplements are necessary. The nurse should inform the
client that the purpose of the folic acid supplement is to do which of the following?
Answer: Prevent certain kinds of birth defects
308) A nurse is observing a client bathe their 1-day-old newborn. Which of the following
actions should the nurse identify as an indication that the client understands how to bathe the
newborn?
Answer: The client washes the newborn's hair before unwrapping them
309) A nurse is assisting in the care of a client who is in preterm labor and is receiving
betamethasone. Which of the following actions should the nurse take?
Answer: Inject the medication into the client's vests laterals muscle
310) A nurse in a provider's office is assisting in the care of an adolescent. Which of the
following findings should the nurse identify as requiring further evaluation?
Answer: Sexual Activity Last Menstrual period
Pain in abdomen
Temperature Vulvar edema
Vaginal Discharge
311) The nurse determines the adolescent's findings are consistent with which of the
following conditions?
Answer: • Abdominal pain-gonorrhea
• Greenish discharge-gonorrhea
• Vulvar Edema-gonorrhea, candidiasis
• Urinary manifestations- gonorrhea, candidiasis
312) The nurse is continuing to care for the adolescent. Which of the following should the
nurse take?
Answer: Administer ceftriaxone into the ventrogluteal muscle

Reinforce education to the adolescent about safe sex practice
313) The nurse should anticipate a provider's prescription for
Answer: Ceftriaxone Doxycycline
314) The nurse is reviewing the provider's prescription in the adolescent's medical chart. The
nurse should first implement...
Answer: Reinforcing education on medication Administering ceftriaxone
315) A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old
newborn. Which of the following statements should the nurse identify as an indication that
the client understands the instructions?
Answer: "I should wake up my baby to feed during the night"
316) A nurse in a prenatal clinic is assisting in the care of a client who is at 16 weeks of
gestation and has a positive hepatitis B test result. Which of the following actions should the
nurse take?
Answer: Explain to the client that they will receive the hepatitis B immune globulin
immediately
317) A nurse is assisting with the care of a client who is postpartum and is receiving lactated
Ringer's 1,500 ml IV to infuse over 10 hr. The nurse should verify that the IV pump's setting
will deliver how many mL/hr?
Answer: 150 mL/hr
318) A nurse is contributing to the plan of care for a client who is pregnant and has
intermittent constipation. Which of the following interventions should the nurse recommend
in the plan?
Answer: Drink 2 L of water per day
319) A nurse is reinforcing teaching about food source high in folate with a group of clients
who are pregnant. Which of the following foods should the nurse recommend to this group as
the best source of folate?
Answer: 1/2 cup dried peas

320) A nurse is collecting data from a client who is receiving magnesium sulfate IV for
preeclampsia. The nurse should identify which of the following findings as an indication of
toxicity to report to the provider?
Answer: Respiratory rate 10/min
321) A nurse on a postpartum unit is organizing care for a group of clients after receiving
change-of- shift report. Which of the following clients should the nurse plan to see first?
Answer: A client who is receiving methylergonovine and has a blood pressure of 148/96
mmHg
322) A nurse is preparing to administer phytonadione to a newborn. The nurse should plan
administer the medication by which to of the following routes?
Answer: Intramuscular
323) A nurse is collecting data from a client who is primigravida and has hyperthyroidism.
Which of the following findings should the nurse expect?
Answer: Diaphoresis
324) A nurse is reinforcing family planning options with a client who is requesting
information about contraceptives. Which of the following client statements indicates an
understanding of the teaching?
Answer: "I can use water-soluble lubricant when my partner wears a latex condom"
325) A nurse is planning to administer terbutaline to a client who is experiencing preterm
labor. Which of the following routes of administration should the nurse plan to use?
Answer: Subcutaneous
326) A nurse is collecting data from a newborn whose mother had gestational diabetes
mellitus. Which of the following findings should the nurse report to the provider?
Answer: Hypoglycemia
327) A nurse in a prenatal clinic is assisting in the care of a group of clients. Which of the
following clients should the nurse recommend the provider see first?

Answer: A client who is at 37 weeks of gestation and reports a persistent headache
328) A nurse is assisting in the care of a client following a cesarean birth. Which of the
following actions should the nurse take to decrease the client's risk of developing
thrombophlebitis?
Answer: Have the client ambulate several times each day
329) A nurse is reinforcing teaching with a client who is at 8 weeks of gestation. Which of the
following responses by the client indicates an understanding of the teaching?
Answer: "I should expect to have white vaginal discharge during pregnancy"
330) A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the
following laboratory findings should the nurse identify as a finding associated with neonatal
sepsis and report to the provider?
Answer: WBC count
331) A nurse is contributing to the plan of care for a client who has hyperemesis gravid arum.
Which of the following interventions should the nurse recommend?
Answer: Monitor intake and output
332) A nurse is assisting with planning care for a client who is breastfeeding and has mastitis.
Which of the following recommendations should the nurse include?
Answer: Instruct the client to apply warm compresses to the affected breast
333) A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic
uterus and excessive vaginal bleeding. Which of the following actions should the nurse take
first?
Answer: Provide fundal massage for the client
334) A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has
respiratory distress. Which of the following findings should the nurse report to the provider?
(select all that apply)
Answer: • Nasal flaring
• Retractions

• Tachypnea
• Expiratory
335) A nurse is contributing to the plan of care for a client who is at 18 weeks gestation and
has just learned that the fetus has trisomy 21. Which of the following resources should the
nurse recommend for the client?
Answer: Genetic counseling
336) A nurse is planning to reinforce discharge teaching about formula feeding with the
parent of a newborn. Which of the following instructions should the nurse plan to include?
Answer: Provide the newborn with six to eight feedings during a 24-hr period
337) A nurse is reinforcing discharge teaching about methods to prevent engorgement during
lactation suppression with a client who is bottle-feeding her newborn. Which of the following
statements should the nurse identify as an indication that the client understands the
instruction?
Answer: "I will apply cold cabbage leaves to my breasts through the day"
338) A nurse on a postpartum unit is contributing to the discharge teaching plan for a client.
Which of the following instructions should the nurse suggest for the plan?
Answer: Use a firm mattress in the newborn's crib
339) A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the
following findings should the nurse report to the provider?
Answer: Uterine contractions.
340) The client is experiencing regular uterine contractions and cervical change, which are
indicators of preterm labor; therefore, the nurse should notify the provider about this finding.
Answer: Gestational age.
341) The client is at 32 weeks of gestation and is experiencing regular uterine contractions
and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse
should notify the provider about this finding.
Answer: Vaginal examination.

Rationale:
The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in
preterm labor; therefore, the nurse should notify the provider about this finding.
342) The client's blood pressure is within the expected reference range Blood pressure
130/70mm Hg? what is normal.
Answer: Blood pressure 130/70mm
343) A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which
of the following actions should the nurse take?
Answer: Report the client's condition to the local health department.
Rationale:
The nurse should report the condition to the local health department. HIV is one of the
conditions on the list of Nationally Notifiable Infectious Conditions that is required to be
reported.
Other considerations:
The nurse should tell the client that treatment for HIV will be during the prenatal and
perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug
antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during
pregnancy have been reported to decrease the transmission of the virus to the newborn.
344) A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia
purpura (ITP). Which of the following findings should the nurse expect?
Answer: Decreased platelet count
Rationale:
A client who has ITP has an autoimmune response that results in a decreased platelet count.
Other considerations:
• An increased ESR is an indication of chronic renal failure.
• An increased WBC is an indication of infection.
345) A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The
client states that they are "happy one minute and crying the next." The nurse should interpret
the client’s statement as an indication of which of the following?
Answer: Emotional lability

Rationale:
The nurse should recognize and interpret the client's statement as an indication of emotional
lability. Many clients experience rapid and unpredictable changes in mood during pregnancy.
Intense hormonal changes may be responsible for mood changes that occur during pregnancy.
Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
346) A nurse is assessing the newborn of a client who took a selective serotonin reuptake
inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse
identify as an indication of withdrawal from an SSRI?
Answer: Vomiting
Rationale:
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation,
tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Manifestations of fetal exposure to SSRIs. include: Low birth weight, hypoglycemia,
Tachypnea.
347) A nurse is assessing four newborns. Which of the following findings should the nurse
report to the provider?
Answer: A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
Rationale:
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range
of 36.5 - 37.5 ° C for a newborn and can be an indication of sepsis. Therefore, the nurse
should report this finding to the provider.
Other considerations:
• A newborn should pass the first meconium stool within the first 24 to 48 hr following birth.
Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder.
• Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a
newborn during the first week following birth.
• Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during
the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no
treatment.
348) A nurse is performing a routine assessment on a client who is at 18 weeks of gestation.
Which of the following findings should the nurse expect?

Answer: FHR 152/min
Rationale:
The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in
gestation with an average of approximately 160/min at 20 weeks of gestation.
Other considerations:
• The nurse should expect the client's DTR to be 2+
• From gestational weeks 18 to 32, the height of the fundus is approximately equal to the
number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the
fundal height for this client to be 16 to 20 cm.
• An elevated blood pressure greater or equal to 140/90, may be an indication of
preeclampsia.
349) A nurse is observing a new guardian caring for their crying newborn who is bottle
feeding. Which of the following actions by the guardian should the nurse recognize as a
positive parenting behavior?
Answer: Lays the newborn across their lap and gently sways
Rationale:
This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense
of security for the newborn.
Other considerations:
• The guardian should place the infant in the supine position, not a prone position, in the
bassinet or crib because of the risk of sudden infant death syndrome.
• Rice cereal should not be added to the bottle of a newborn because solids should not be
introduced until 4 to 6 months of age.
• Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However,
formula should not be placed on the tip of the pacifier because the newborn might become
accustomed to it and refuse to take the pacifier in the future without added supplement.
350) A nurse is caring for a newborn who was transferred to the nursery 30 min after birth
because of mild respiratory distress. Which of the following actions should the nurse take
first?
Answer: Verify the newborn's identification.
Rationale:

When using the safety/risk reduction approach to client care, the first action the nurse should
take is to verify the newborn's identity upon arrival to the nursery.
Other considerations:
• The Apgar score is a physiological assessment that occurs 1 min following birth and again
at 5 min. The nurse should confirm the score when the newborn arrives in the nursery.
• The nurse should administer IM vitamin K to the newborn soon after birth to increase
clotting factors and prevent bleeding. However, the injection can be delayed until after initialbonding time and the first breastfeeding if necessary.
• The nurse should identify obstetrical risk factors to determine if interventions are required
for the newborn.
351) A nurse is providing teaching for a client who has a new prescription for combined oral
contraceptives. Which of the following findings should the nurse include as an adverse effect
of this medication?
Answer: Depression
Rationale:
The nurse should instruct the client that depression is a common adverse effect of combined
oral contraceptives. Other common adverse effects of the medication include amenorrhea,
weight gain, headache, nausea, breakthrough bleeding, breast tenderness, hypertension,
abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. Report to
PCP shortness of breath.
352) A nurse is planning care for a client who is in labor and is to have an amniotomy. Which
of the following assessments should the nurse identify as the priority?
Answer: Temperature
Rationale:
The greatest risk for a client following amniotomy is infection. Therefore, the nurse should
identify that the priority assessment is the client's temperature.
353) A nurse is admitting a client to the labor and delivery unit when the client states, "My
water just broke." Which of the following interventions is the nurse's priority?
Answer: Begin FHR monitoring.
Rationale:

The greatest risk to the client and their fetus following a rupture of membranes is umbilical
cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore,
this is the priority action the nurse should take.
Other interventions:
• The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH
can indicate rupture of membranes.
the following assessments should
• The nurse should observe the characteristics of the fluid to document color, odor, and
amount.
• The nurse should check the client's cervical dilation to assess progress of labor.
354) A school nurse is providing teaching to an adolescent about levonorgestrel
contraception. Which of the following information should the nurse include in the teaching?
Answer: "You should take the medication within 72 hours following unprotected sexual
intercourse."
Rationale:
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception.
The nurse should instruct the adolescent to take this medication as soon as possible within 72
hr after unprotected sexual intercourse.
Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore,
the nurse should inform the client that they will not be protected from pregnancy if they have
unprotected sexual intercourse in the days and weeks after receiving this medication. The
adolescent should be evaluated for pregnancy if they do not menstruate within 21 days
following administration of this medication.
355) A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of
gestation. Which of the following conditions is an indication for fetal assessment using
electronic fetal monitoring?
Answer: Oligohydramnios
Rationale:
The nurse should identify that oligohydramnios requires further fetal assessment usingelectronic fetal monitoring.
Other conditions that require further fetal assessment using electronic fetal monitoring
include: hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal

movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and
intrahepatic cholestasis.
356) A nurse is caring for a client who has preeclampsia and is receiving a continuous
infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Answer: Have calcium gluconate readily available.
Rationale:
The nurse should have calcium gluconate readily available to prevent cardiac or respiratory
arrest in the event the client experiences magnesium toxicity .
Other interventions:
• The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of
magnesium sulfate.
• The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine
output should be 30 mL/hr or greater.
• The nurse should monitor intake and output hourly for clients who are receiving a
continuous infusion of magnesium sulfate.
357) A nurse is caring for a client who is in labor and reports increasing rectal pressure. They
are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal
examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the
client is in which of the following phases of labor?
Answer: Active
Rationale:
The nurse should identify that the client is in the active phase of labor. This phase is
characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each
lasting 40 to 90 seconds.
Other considerations:
• The early phase of labor is characterized by cervical dilation of 0 to 5 cm and contractions
every 2 to 30 min, each lasting 30 to 40 seconds.
• The passive descent phase of labor is in the second stage of labor and is characterized by a
period of calm and rest. The fetus continues to descend and rotate through the birth canal.
• The descent phase of labor is characterized by active pushing with contractions every 1 to2
min, each lasting for 90 seconds.

358) A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings should
the nurse report to the provider? Fundal height 30 cm
Answer: Fundal height measurement
Rationale:
A fundal height measurement of 30 cm should be reported to the provider. Fundal height
should be measured in centimeters and is the same as the number of gestational weeks plusor
minus 2 weeks from 18 to 32 weeks gestation. In this case fundal height should be 24-28 cm.
359) A nurse is teaching a postpartum client about steps the nurses will take to promote the
security and safety of the client's newborn. Which of the following statements should the
nurse make?
Answer: "Staff members who take care of your baby will be wearing a photoidentification
badge."
Rationale:
The nurse should instruct the client that all staff members that care for newborns are required
to wear a photo identification badge so that the client will be reassured of the newborn’s
safety. Some units' staff members wear special badges or a specific color scrubs.
Other interventions:
• The nurse should instruct the client that bed sharing is not a safe practice in the hospital or
home environment because it can cause injury to the newborn. - The nurse should instruct the
client that their newborn should sleep supine in a bassinet or crib.
• The nurse should instruct the client that newborns will be transported in their bassinets and
never carried outside the client's room in their arms to reduce the risk for falls.
• The nurse should instruct the client that they can have anyone visit them on the unit. There
is no documentation of a visitor's relationship to the client entered into the medical record.
360) A nurse is teaching a client who is at 10 weeks of gestation about nutrition during
pregnancy. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I should take 600 micrograms of folic acid each day."
Rationale:
A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists
with preventing neural tube birth defects.

Other indications:
• A client who is pregnant should increase caloric intake by 340 cal during the second
trimester and by 452 cal during the third trimester.
• A client who is pregnant should consume 3 L of water each day.
• A client who is pregnant should increase protein intake to 71 g each day during the second
and third trimesters.
361) A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid
replacement. Which of the following findings should the nurse report to the provider?
Answer: Blood pressure 105/64 mm Hg
Rationale:
The nurse should report decreased blood pressure to the provider since it can indicate
dehydration.
Other considerations:
Testing the urine for ketones is the most important laboratory test for a client who has
hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration,
which increases the risk of preterm labor. A negative test result is an expected finding.
Therefore, the nurse does not need to report this finding to the provider.
362) A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence
the nurse should follow. (Move the steps into the box on the right, placing them in the order
of performance. Use all the steps.)
Answer: • The first step the nurse should take when performing Leopold maneuvers is to
palpate the client's fundus to identify the fetal part.
• Second, the nurse should determine the location of the fetal back.
• Third, the nurse should palpate for the fetal part presenting at the inlet.
• Finally, the nurse should palpate the cephalic prominence to identify the attitude of the
head.
363) A nurse is providing dietary teaching to a client who has hyperemesis gravidarum.
Which of the following statements by the client indicates an understanding of the teaching?
Answer: "I will eat foods that taste good instead of balancing my meals."
Rationale:

Clients who have hyperemesis gravidarum should eat foods they like in order to avoid
nausea, rather than trying to consume a well-balanced diet.
Other considerations:
• Clients who have hyperemesis gravidarum should avoid going to bed with an empty
stomach. The nurse should instruct the client to eat a healthy snack before going to bed.
• Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3hr
to avoid an empty stomach and over filling at each meal.
• The client should be encouraged to consume dairy products, because they are less likely to
cause nausea than other foods.
364) A nurse is transporting a newborn back to the parent's room following a procedure.
Which of the following actions should the nurse take prior to leaving the newborn with their
parent?
Answer: Ensure that the parent's identification band number matches the newborn's
identification band number.
Rationale:
The nurse should verify the newborn's identity every time the newborn is returned to the
parents. The nurse should match the number on the parent's identification band to the number
on the newborn's identification band.
365) A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations
should the nurse report to the provider? Answer: Jaundice
Rationale:
Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility,
hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.
Other manifestations:
• Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a
newborn 24 to 48 hr after birth.
• Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the
occiput.
• Transient strabismus is a normal variation in the newborn's eyes that can persist until the
third or fourth month of age.

366) A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following
findings should the nurse report to the provider? Answer: The nurse should report these findings to the provider.
Rationale:
• Abdominal assessment.
Abdominal tenderness with palpation is not an expected finding with an abdominal
assessment
• Vaginal discharge.
Greenish vaginal discharge indicates that the adolescent has an infection, which is not an
expected finding
• Temperature is correct. The client's temperature of 38.3° C (101° F) is above the expected
reference range. An elevated temperature could signal infection or inflammation
• Dyspareunia.
Dyspareunia is painful intercourse, which can be associated with STIs
• Condom usage.
Sexual activity without the use of condoms increases the risk of contracting STIs
367) For each finding, click to specify if the assessment findings are consistent with
trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease
process.
Answer: - Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports
of acute or chronic lower abdominal pain.
Rationale:
• Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow
discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white,
lumpy discharge.
• Diabetes is consistent with candidiasis. Diabetes is a predisposing factor for yeast infections
environment with enough glucose to allow the growth of yeast.
because high glucose levels provide an
• Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a
manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the result of urine
flowing over an irritated and inflamed vulva and surrounding skin.

• Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity
without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal
infection that is not sexually transmitted.
368) The nurse is reviewing the adolescent's medical record. Which of the following
conditions is the client most likely developing?
Answer: Pelvic inflammatory disease.
Rationale:
• Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive
organs. There are several causative agents that lead to infection, including Neisseria
gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending
from the vagina.
• Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore,
the nurse should suspect the adolescent is developing PID.
• C-reactive protein. The adolescent's C-reactive protein is elevated, which is a manifestation
of PID.
369) The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is
planning care. Which of the following prescriptions should the nurse expect the provider to
prescribe?
Answer: Ceftriaxone and doxycycline.
Rationale:
The nurse suspects that the adolescent is experiencing pelvic inflammatory disease (PID);
Therefore, the nurse should anticipate a provider's prescription for ceftriaxone and
doxycycline. The recommended treatment for PID in an outpatient setting is ceftriaxone
administered as a single dose intramuscularly, along with doxycycline administered orally
2x/day for 14 days. The treatment regimen may change following the results of the cervical
culture.
370) The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.
Answer: Providing education on medications .
Rationale:
The nurse should first educate the adolescent regarding medications because clients have the
right to know the purpose and potential adverse reactions of all prescribed medications before

receiving them. An understanding of the prescribed medications will increase the likelihood
that the adolescent will adhere to the prescribed therapy.
• Administering ceftriaxone.
Ceftriaxone is designated as a NOW prescription, which means it should be given within 90
min of the provider writing the prescription. The nurse should administer ceftriaxone after
educating the adolescent about the purpose and potential adverse reactions of the medication.
371) The nurse has just reviewed discharge instructions with the adolescent. Which of the
following indicates whether the adolescent understands the teaching or requires further
education?
Answer: Indicates understanding:
Rationale:
• "I should continue taking all my medications even if I don't show any symptoms"
• "If I continue to get this type of infection, it can affect my ability to have kids in the future”
repeated instances of PID can cause infertility.
• "I'm more likely to get a sunburn while taking these medications" The nurse informed the
adolescent that they might experience increased sensitivity to sunlight while using
doxycycline and that they should use sunscreen and wear protective clothing while taking the
medication.
Requires further education:
• "I should go to the emergency department if my urine turns dark" The nurse informed the
adolescent that while taking metronidazole their urine might turn dark, they should not be
alarmed because dark urine is an adverse effect of taking this medication.
• "As long as I keep my IUD, I don't need to use condoms" The nurse informed the
adolescent that they should use a condom to decrease the risk of contracting an STI; IUDs
effectively prevent pregnancy, not STIs.
372) A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which client's history should the nurse recognize as a of the following findings
in the contraindication to oral contraceptives? (Select all that apply.)
Answer: Contraindication for the use of oral contraceptives.
• Cholecystitis
• Hypertension
• Migraine

373) A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus
to the right above the umbilicus. Which of the following interventions should the nurse
perform?
Answer: Assist the client to empty their bladder .
Rationale:
The nurse should assist the client to empty their bladder because the assessment findings
indicate that the client's bladder is distended. This can prevent the uterus from contracting,
resulting in increased vaginal bleeding or postpartum hemorrhage.
374) A nurse on an antepartum unit is caring for four clients. Which of the following clients
should the nurse identify as the priority?
Answer: A client who is at 34 weeks of gestation and reports epigastric pain
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should assess the
client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and
indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should
identify this client as the priority.
Non urgent findings:
• A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who
has gestational diabetes
• A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL) This
finding is a manifestation of anemia in a client who is pregnant
• A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Dysuria
can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who
is at 39 weeks of gestation is a nonurgent condition, which will require antibiotics.
375) A nurse is assessing a late preterm newborn. Which of the following manifestations is an
indication of hypoglycemia?
Answer: Respiratory distress
Rationale:
Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen
stores and immature insulin secretion. Respiratory distress is a manifestation of

hypoglycemia. Other manifestations of hypoglycemia include hypothermia, poor feeding
behaviors, hypotonia, an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
376) A nurse is caring for a client who is at 10 weeks of gestation. Which of the following
findings should the nurse report to the provider?
Answer: Frequent vomiting with weight loss of 3 lbin 1 week
Rationale:
The nurse should recognize that frequent vomiting with a weight loss of 3 lb in 1 week may
indicate hyperemesis gravidarum and should be reported to the provider. The client could
experience electrolyte imbalances due to hyperemesis gravidarum.
Common findings during the first trimester of pregnancy:
• emotional lability and mood swings
• Nosebleeds occurring approximately 3 times per week. (epistaxis)
• increased vaginal discharge, or leukorrhea
377) A nurse is caring for a client who is at 41 weeks of gestation and has a positive
contraction stress test. For which of the following diagnostic tests should the nurse prepare
the client?
Answer: Biophysical profile (BPP)
Rationale:
The nurse should prepare the client for a BPP to further assess fetal well-being. A positive
contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a
real time ultrasound to visualize physical and physiological characteristics of the fetus and
observe for fetal biophysical responses to stimuli.
Other tests:
• An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity
through a transcervical catheter introduced into the uterus to supplement the amount of
amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord
compression for clients who are in labor.
• CVS is the assessment of a portion of the developing placenta, which is aspirated through a
thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix
under ultrasound guidance. This procedure is done during the first trimester.

• Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most
common method used for fetal blood sampling and transfusion. This is not a diagnostic test
used for clients who have a positive contraction stress test.
378) A nurse is planning care for a client who is to undergo a nonstress test. Which of the
following actions should the nurse include in the plan of care?
Answer: Instruct the client to press the provided button each time fetal movement is
detected.
Rationale:
Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to
press the button when they detect fetal movement will ensure that the fetal movement is
noted.
Other considerations:
• The client should be placed in a semi-Fowler's or sitting position and tilted to the right or
left to promote uterine perfusion and prevent supine hypotension.
• There is no indication for the client to be NPO. Sometimes clients are encouraged to drink
liquids to promote adequate hydration.
• To stimulate fetal movement use a buzzer or give the client orange juice to wake up the
baby
379) A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal monitoring?
Answer: Perform Leopold maneuvers.
Rationale:
The nurse should perform Leopold maneuvers to assess the position of the fetus to best
determine the optimal placement for the external fetal monitoring transducer.
Note:
The nurse should determine the client's dilation and effacement prior to applying an internal
monitor. This action is not required prior to applying an external transducer for fetal
monitoring.
380) A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of
the following findings contraindicates the initiation of the oxytocin infusion and should be
reported to the provider?

Answer: Late decelerations
Rationale:
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a
contraindication for the administration of oxytocin and should be reported to the provider.
Other considerations:
• Cessation of uterine dilation and a prolonged active phase of labor are indications for the
initiation of an oxytocin infusion to augment the client's labor progression.
• Moderate variability of the FHR is an expected assessment finding associated with normal
fetal acid-base balance. It is not a contraindication to the administration of oxytocin.
381) A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has an
amniocentesis. Which of the following just had interventions is the nurse's priority following
the procedure?
Answer: Monitor the FHR .
Rationale:
The greatest risk to this client and their fetus is fetal death due to blood mixing. Therefore,
the priority nursing intervention is to monitor the FHR following an amniocentesis.
Other considerations:
• The nurse should check the client's temperature to monitor for infection following an
amniocentesis.
• The nurse should administer Rho(D) immune globulin following an amniocentesis to
prevent Rh sensitization.
• The nurse should observe for uterine contractions to identify preterm labor following an
amniocentesis.
382) A nurse is planning care for a client who is in labor and is requesting epidural anesthesia
for pain control. Which of the following actions should the nurse include in the plan of care?
Answer: Monitor the client's blood pressure every 5 min following the first dose of
anesthetic solution.
Rationale:
The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic
solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10
min to assess for maternal hypotension caused by the anesthetic solution.
Other considerations:

• The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium
chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to
decrease the maternal risk for hypotension. The nurse should not administer dextrose because
it can cause maternal hyperglycemia and neonatal hypoglycemia
• The nurse should plan to position the client upright to allow the anesthetic solution to flow
downward. If additional pain management is needed for a cesarean birth, the nurse can place
the client supine with their head and shoulders elevated and at a lateral tilt to increase
perfusion to the fetus.
• NPO status is not indicated for this procedure
383) A nurse is assessing a newborn following a circumcision. Which of the following
findings should the nurse identify as an indication that the newborn is experiencing pain?
Answer: Chin quivering
Rationale:
Behavioral responses to a newborn's pain include facial expressions such as chin quivering,
grimacing, and furrowing of the brow.
When a newborn is experiencing pain:
• The heart rate will increase
• newborn's pupils typically dilate
• newborn's respirations are typically rapid and shallow
384) A nurse is preparing to administer azithromycin to a client who is at 16 weeks of
gestation and has a positive chlamydia culture. The prescription states "Administer
azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the
nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it
applies. Do not use a trailing zero.)
Answer: 4
385) A nurse is caring for a client who becomes unresponsive upon delivery of the placenta.
Which of the following actions should the nurse take first?
Answer: Determine respiratory function.
Rationale:

The first priority action the nurse should take when using the airway, breathing, circulation
approach to client care is to determine respiratory function and the need for cardiopulmonary
resuscitation.
Other interventions:
• The nurse should increase the IV fluid rate to maintain circulation.
• The nurse should access emergency medications from cart to assist in resuscitative efforts
• The nurse should collect a maternal blood sample in preparation for a blood transfusion
386) A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal
visit. Which of the following findings should the nurse report to the provider?
Answer: Swelling of the face
Rationale:
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves
out of the intravascular compartment into the tissues, causing edema.
Other findings:
• Varicose veins are an expected finding in the second trimester. The increase in hormones
during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading
to vessel dilation and Vaso congestion. Additionally, the weight of the enlarging uterus on the
pelvic veins decreases the return of blood from the lower extremities.
• Hyperpigmentation of the cheeks, areola, vulva, and line a nigra are expected findings in the
second trimester. The anterior pituitary increases the production of melanocyte-stimulating
hormone, which leads to hyperpigmentation of the skin.
• Nonpitting edema of the lower extremities is an expected finding in the third trimester.
Warm weather, sitting or standing for prolonged periods of time, and tight clothing can
increase edema.
387) A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients
should the nurse see first?
Answer: A client who is at 11 weeks of gestation and reports abdominal cramping
Rationale:
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a client who is at 11 weeks of gestation and reports abdominal
cramping.

Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous
abortion. The nurse should request that the provider see this client first.
Other considerations:
• Tingling and numbness of the right hand is nonurgent because it is a common discomfort
related to pregnancy for a client who is at 15 weeks of gestation.
• Constipation is nonurgent because it is a common discomfort related to pregnancy for a
client who is at 20 weeks of gestation.
• A client who is at 8 weeks of gestation and reports having three bloody noses in the past
week (Epistaxis) is nonurgent because it is a common discomfort related to pregnancy for a
client who is at 8 weeks of gestation.
388) A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a
nonstress test. Which of the following instructions should the nurse include?
Answer: "You should press the handheld button when you feel your baby move."
Rationale:
The nurse should instruct the client to press the handheld button when the fetus moves. This
action will mark the fetal monitor tracing with the client's reports of fetal movement. This
will assist in the interpretation of the nonstress test to determine if it is reactive or
nonreactive.
Other interventions:
• The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's
position with a slight lateral tilt to ensure optimal uterine perfusion.
• The client is not required to be NPO before or during the procedure. The nurse can suggest
the client drink orange juice to increase their blood glucose level which will stimulate feta
movements.
• The nurse should instruct the client that the nonstress will take approximately 20 to 30 min,
but more time might be required if the fetus is in a sleep state when the testing begins.
389) A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the
following findings is an indication for the administration of the medication? (Select all that
apply.)
Answer: • Flaccid uterus. Oxytocin increases the contractility of the uterus.
• Excess vaginal bleeding. Oxytocin enhances uterine contractility, decreasing vaginal
bleeding.

Other considerations:
• The use of oxytocin will increase, rather than decrease, afterbirth cramping
• Bleeding resulting from a cervical laceration continues even when the uterus is contracted
and firm. It will require repair by the provider.
• The use of oxytocin will have no effect on maternal temperature
390) A nurse is assessing a newborn who was born at 26 weeks of gestation using the New
Ballard Score. Which of the following findings should the nurse expect?
Answer: Minim alarm recoil
Rationale:
The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased
muscular tone, or minimal arm recoil.
What is the New Ballard Score
• Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing
gestational age after 26 weeks.
• Creases over the entire sole of a newborn's foot are an indicator of physical maturity with
increasing gestational age after 26 weeks.
• A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age
after 26 weeks.
391) A nurse is caring for a newborn, specify if the finding is consistent with hypoglycemia,
hyperbilirubinemia, or sepsis.
Answer: Hypoglycemia: Decreased temperature, poor feeding, respiratory distress, and
lethargy
Rationale:
• Hyperbilirubinemia: Yellow sclera and oral mucosa, and poor feeding. A newborn with an
ecchymotic caput succedaneum is at higher risk for hyperbilirubinemia.
• Sepsis: decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory
distress, and lethargy
Notes:
• Caput succedaneum is swelling of the scalp in a newborn. It is most often brought on by
pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Swelling and
bruising usually occur on the top of the scalp where the head first enters the cervix during
birth.

• hypoglycemia is a cause for delayed bilirubin elimination along with hypoxia, hypothermia,
and sepsis.
392) A nurse is caring for a newborn who is 70 hr old. Which of the following findings
should the nurse report to the provider?
Nurse notes:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased
muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted.
Several loose stools today.
Heart rate 160/min Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Answer: • Central nervous system findings. The newborn is displaying inconsolability, highpitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking.
These findings are manifestations of NAS and should be reported to the provider.
• Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose
stools. These findings are manifestations of NAS and should be reported to the provider
Other considerations:
• Newborn's oxygen saturation reference range of greater than 94%.
• Newborn's temperature expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F)
• Newborn's respiratory rate reference range of 30 to 60/min. Report alteration in respiratory
status
• Neonatal Abstinence Syndrome (also called NAS) is a group of conditions caused when a
baby withdraws from certain drugs he's exposed to in the womb before birth. NAS is most
often caused when a woman takes drugs called opioids during pregnancy. - Hyperactive Moro
reflex.
The Moro reflex is a normal reflex for an infant when he or she is startled or feels like they
are falling. The infant will have a startled look and the arms will fling out sideways with the
palms up and the thumbs flexed. Absence of the Moro reflex in newborn infants is abnormal
and may indicate an injury or disease.
393) A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

Answer: Remove all clothing from the newborn except the diaper.
Rationale:
The nurse should remove all the newborn's clothing except the diaper while under
phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the
excess bilirubin.
Other considerations:
• The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary,
fine rash can occur during therapy. This rash requires no treatment.
• The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing
phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns.
• The nurse should not feed the newborn any water or glucose water. Hydration can be
maintained through regular breastfeeding or formula feeding. Water and glucose water don’t
increase the excretion rate of bilirubin in the stool or provide nutritional value.
394) A nurse is teaching a client who has pregestational type 1 diabetes mellitus about
management during pregnancy. Which of the following statements by the client indicates an
understanding of the teaching?
Answer: "I will continue taking my insulin if I experience nausea and vomiting."
Rationale:
The nurse should teach the client to continue to take their insulin as prescribed during illness
to prevent hypoglycemic and hyperglycemic episodes.
Other interventions:
• The nurse should teach the client to avoid snacks and foods that are high in refined sugar. To
control hypoglycemic episodes, the nurse should instruct the client to consume a lowcarbohydrate, high-protein diet, avoid fasting, and avoid simple sugars
• The nurse should teach the client to avoid exercise during periods of hyperglycemia and
when positive urine ketones are present.
• The nurse should teach the client that their blood glucose levels are normally reduced and
insulin response is enhanced during the first trimester of pregnancy which may require less
insulin to control blood glucose levels.
395) A nurse is caring for a newborn who is 48 hr old. Specify what condition the client is
most likely experiencing, 2 actions the nurse should take to address that condition, and 2
parameters the nurse should monitor to assess the client's progress.

Heart rate 174/min Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL
Newborn awake, alert, and crying. Loosely wrapped in one blanket. Mild tremors noted.
Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no
retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and
transitional stool.
Answer: Upon recognizing and analyzing newborn findings of temperature below the
expected range, respiratory rate above the expected range, and hypoglycemia, the nurse's
priority hypothesis is that this newborn is most likely experiencing cold stress.
2 actions the nurse should take are: Place newborn skin to skin on birthing parent's chest, and
Encourage birthing parent to breastfeed .
It is important to generate solutions and take actions that address cold stress. Therefore, the
nurse should monitor the newborn's temperature and glucose levels because a newborn
experiencing cold stress is at risk for developing metabolic acidosis. To evaluate the client's
response to these interventions, the nurse should monitor the newborn's temperature and
glucose levels.
396) A nurse is caring for a newborn. Which of the following actions should the nurse plan to
implement? specify if the intervention is indicated or contraindicated for the newborn.
Apgar score 9 at 1 min and 9 at 5 min Birth weight
4,706 g (10 lb 6 oz) Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia.
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm
pronated with wrist and fingers flexed.
Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis.
Answer: Indicated:
• Educate the parents to begin range of motion exercises on the affected arm after 1 week.
Passive ROM exercises of the arm are indicated to restore function of the extremity. The
initiation of these exercises is delayed for approximately 1 week to prevent additional injury
to the brachial plexus.

• Assess for grasp reflex in the affected extremity. With Erb-Duchenne paralysis, only the
upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse
should assess for a palmar grasp reflex.
• Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
Intermittent immobilization of the affected arm across the newborn's abdomen can be
achieved by pinning the sleeve to the shirt.
Contraindicated
• Instruct parents to limit physical handling for 2 weeks. Parents and guardians should
participate in the physical care of their newborn to increase parental-infant attachment.
Providing education and practice opportunities for the parents will decrease their fears of
injuring the newborn and increase confidence and bonding.
397) A nurse on an antepartum unit is caring for a client. Specify if the intervention is
indicated or contraindicated for the client.
0900:
Temperature 36.2°C (97.2° F)
Pulse rate 78/min
Respiratory rate 20/min
Blood pressure 112/64 mm Hg
Fetal heart rate 132/min
0930:
Pulse rate 82/min
Blood pressure 116/60 mm Hg
Fetal heart rate 160/min
Client passed large amount of bright red blood from vagina. Denies pain. Uterine tone soft
and nontender to palpation.
Contraction pattern: no contractions noted .
Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
30 weeks gestation
Previous pregnancies delivered via caesarean section
Answer: Indicated:
• Insert a large bore intravenous catheter..

Clients who have third trimester vaginal bleeding may experience a sudden hemorrhage and
require fluid resuscitation or the administration of blood products. - Weigh perineal pads.
The nurse should weigh perineal pads. Weighing perineal pads after use will provide a more
accurate assessment of the volume of blood loss that the client is experiencing.
Contraindicated:
• Administer methotrexate.
The nurse should not administer methotrexate. Methotrexate is an antimetabolite and folic
acid antagonist which destroys rapidly dividing cells. It can be administered during
pregnancy to medically resolve an ectopic pregnancy during the first trimester. - Assess
cervical dilation.
The nurse should not assess for cervical dilation.
Assessing cervical dilation is contraindicated for any pregnant client who is experiencing
vaginal bleeding. Manipulation of the cervix during the examination may result in further
damage to the placenta and compromise the well-being of the client and fetus.
398) A nurse is teaching a client who is at 35 weeks of gestation about manifestations of
potential pregnancy complications to report to the provider. Which of the following
manifestations should the nurse include?
Answer: Headache that is unrelieved by analgesia
Rationale:
A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported
to the provider.
Expected manifestation at 35 weeks of gestation:
• Shortness of breath when climbing stairs. Shortness of breath is related to the enlarging
uterus interfering with the expansion of the diaphragm
• Swelling of feet and ankles at the end of the day. Swelling of feet and ankles is due to the
enlarging uterus sitting at the pelvic area and interfering with blood return to the heart.
• Braxton Hicks contractions.
Braxton Hicks contractions are an indication that the uterus is preparing for labor
399) A nurse is assessing a newborn who is 16 hr old. Which of the following findings should
the nurse report to the provider?
Answer: Substernal retractions
Rationale:

The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and
tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The
nurse should report these findings to the provider for immediate intervention.
Other considerations:
• A head circumference of 33 cm is within the expected reference range for a newborn
following birth.
• Overlapping suture lines with molding are an expected variation for newborns who were
delivered vaginally. - Acrocyanosis is an expected finding in the newborn for the first 24 hr
following birth.
400) A nurse is caring for a client following an amniocentesis at 18 weeks of gestation.
Which of the following findings should the nurse report to the provider as a potential
complication?
Answer: Leakage of fluid from the vagina
Rationale:
Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and
should be reported to the provider.
Other considerations:
• Decreased fetal movement is a potential complication that should be reported to the
provider.
• Upper abdominal discomfort is not a potential complication associated with an
amniocentesis. - Urinary frequency is not a potential complication associated with an
amniocentesis.
401) A nurse is caring for a postpartum client who is receiving heparin via a continuous IV
infusion for thrombophlebitis in their left calf. Which of the following actions should the
nurse take?
Answer: Maintain the client on bed rest.
Rationale:
The client should remain on bed rest to decrease the risk of dislodging the clot, which could
cause a pulmonary embolism. Elevation of the affected leg is recommended.
Other considerations:
• A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because
it can lead to prolonged clotting times and increased risk of bleeding.

• The nurse should avoid massaging the affected leg to decrease the risk of dislodging the
clot, which could cause a pulmonary embolism.
• The nurse should apply warm compresses to the affected area to promote circulation and
decrease edema.
Extra questions from review
402) A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis
gravidarum. The nurse should identify that which of the following are risk factors for the
client?
Answer: Risk factors for hyperemesis gravidarum which include:
• diabetes
• multifetal pregnancy.
• Gestational trophoblastic disease
• Clinical hyperthyroid disorders
• Maternal age younger than 30 years
• Psychosocial issues and high levels of emotional stress
• Gastrointestinal disorders
• Family history of hyperemesis
403) A nurse is discussing with a newly licensed nurse gestational diabetes mellitus. Which
of the following risk factors should the nurse include in the teaching for the condition?
Answer: Gestational diabetes mellitus has some of the following as risk factors for the
condition which includes: Maternal age older than 25 years old, and a previous birth of an
infant who was large or stillborn.
404) A nurse is discussing with a newly licensed nurse gestational hypertension. Which of the
following risk factors should the nurse include in the teaching for the condition?
Answer: Some risk factors for gestational hypertension include: Maternal age older than 40
years, and first pregnancy.
405) A nursing is assisting with the care of a client who is receiving IV magnesium sulfate.
Which of the following medications should the nurse anticipate administering if magnesium
sulfate toxicity is suspected?

Answer: Calcium gluconate is the antidote for magnesium sulfate and should be readily
available for client's who are receiving magnesium sulfate IV. Administer antidote calcium
gluconate or calcium chloride.
406) A nurse is assisting with the care of a client who has severe preeclampsia who is
receiving magnesium sulfate IV. Which of the following findings should the nurse identify
and report as magnesium sulfate toxicity?
Answer: The following findings the nurse should report as magnesium sulfate toxicity:
• Absence of patellar deep tendon reflexes
• Urine output less than 30 mL/hr
• Respirations less than 12/min
• Decreased level of consciousness
• Cardiac dysrhythmias
• Flushing and sweating are adverse effects of magnesium sulfate but are not manifestations
of toxicity.
407) A nurse is preparing to teach a client who is at 20 weeks of gestation and is scheduled to
undergo a prophylactic cervical cerclage. What information should the nurse include in the
teaching?
Answer: Description of Procedure: Surgical reinforcement of the cervix with a heavy ligature
(suture) that is placed submucosally around the cervix to strength it and prevent premature
cervical dilation.
Potential Complications
• Uterine contractions
• Rupture of membranes
• Infection
• Client Education
• Remain on activity restrictions/bed rest as prescribed.
• Increase hydration to promote a relaxed uterus. Refrain from sexual intercourse.
• Findings to report to the provider include preterm labor, rupture of membranes,
manifestations of infection, strong contractions less than 5 min apart, perineal pressure, and
the urge to push.
• Plan for removal of the cerclage between 37 and 38 weeks of gestation.

408) A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent
ophthalmia neonatorum. which of the following medications should the nurse anticipate
administering?
Answer: Erythromycin
409) A nurse is reinforcing teaching about breastfeeding with the mother of a newborn. which
of the following actions indicates understanding of the teaching?
Answer: when latched on, the infant's nose, cheek, and chin are touching the mother's breast
410) A nurse is reinforcing teaching about proper techniques for bottle feeding with a new
mother which of the following instructions should the nurse provide
Answer: Keep the nipple full of formula.
411) A nurse is discussing circumcision with a newly hired nurse. which of the following
conditions should the nurse identify as contraindications? (select all that apply.)
Answer: • Hypospadia
• family history of hemophilia
•epispadia
412) A nurse is admitting a client who is in labor and has an HIV infection HIV. the nurse
should identify that HIV infection is a contraindication to which of the following
interventions? (select all that apply.)
Answer: • episiotomy
• forceps
• internal fetal monitoring
413) A nurse is inspecting the perineal pad of a client who is 24 hr postpartum. the pad is
saturated with approximately 12 cm of dark-red discharge. Which of the following blood loss
estimations should the nurse report to the charge nurse and document in the client's medical
record?
Answer: Moderate

414) A nurse is reinforcing discharge teaching with a postpartum client who had no immunity
to varicella and received the varicella vaccine. Which of the following client statements
indicates understanding of the teaching?
Answer: I need a second vaccination at my postpartum visit.
415) A nurse is reinforcing teaching with a client who is 1 week postpartum and
breastfeeding the client reports breast engorgement. Which of the following instructions
should the nurse give to the client
Answer: apply cold compresses between feedings.
416) A nurse is reinforcing discharge instructions with a client who is 4 weeks postpartum.
the nurse should instruct the client to contact her provider for which of the following
findings?
Answer: sore nipple with cracks and fissures
417) A nurse is reinforcing discharge teaching with a postpartum client following a cesarean
birth. the client reports leaking urine every time she sneezes or coughs. Which of the
following interventions should the nurse suggest to the client?
Answer: Kegel exercises
418) A nurse in an assisted living facility is caring for an older adult client. the nurse should
recognize that older adults have decreased absorption of which of the following? (select all
that apply.)
Answer: • calcium
• folic acid
419) A nurse is assessing a 6-month-old infant who has a lactose intolerance. Which of the
following findings should the nurse expect? (select all that apply
Answer: •Abdominal distention
• flatus
• occasional diarrhea
420) A nurse is educating the parents of a toddler about appropriate snack foods. Which of
the following foods should the nurse include in the teaching? (select all that apply.)

Answer: • Graham crackers
• Apple slices
• cheese cubes
421) A nurse is teaching a group of pregnant clients about iron-rich foods. Which of the
following foods should the nurse include in the teaching? (select all that apply.)
Answer: • Beans
• fish
• Dairy products
• Lean red meats
422) A school nurse is teaching a group of teens about healthy snack food choices. Which of
the following foods should the nurse include in the teaching? (select all that apply).
Answer: • carrot sticks with low-fat dip
• cheese and crackers -unbuttered popcorn
423) A nurse is assisting with the care of a client who is at 42 weeks gestation and in labor.
the client asks the nurse what should she expect because her baby is postmature. which of the
following statements should the nurse make?
Answer: Your baby’s skin will appear leathery
424) A nurse is caring for an infant who has a high bilirubin level and is receiving
phototherapy. Which of the following is the priority finding in the newborn?
Answer: Sunken fontanels
425) A nurse is assisting with data collection of a newborn who was born at 32 weeks of
gestation. the newborn's birth weight is 1,100 g. which of the following findings should the
nurse expect? (select all that apply.)
Answer: • lanugo -Weak grasp reflex
• Translucent skin
426) A nurse is assisting with data collection of a post term newborn. which of the following
findings should the nurse expect? (select all that apply)
Answer: • Thin with loose skin

• meconium staining of umbilical cord .
• long finger nails
427) Tonic neck reflex
Answer: When the newborns head is turned quickly to one side, the arm and legs on the
same side extend, the arm and leg on the opposite side flex
428) Platelet count normal
Answer: 150,000-300,000
429) Methylergonovine adverse reaction
Answer: hypertension
430) Foods that are high in folate
Answer: dried peas
431) Butorphanol tartrate side effects
Answer: Opioid medication may cause dizziness
432) Terbutaline is given
Answer: Subcutaneous
433) Hypovolemic shock
Answer: Insert a catheter
434) Hematocrit normal
Answer: 33%
435) nifedipine contradicted with what medication
Answer: Magnesium sulfate
436) Risk factor for developing pre-eclampisa
Answer: Rheumatoid arthrtitis

437) A nurse is collecting data from a client who is a primigravida and has hyperthyroidism.
Which findings should the nurse expect?
Answer: diaphoresis
438) A nurse in a postpartum unit is caring for a client who has endometritis and is 48 hrs
postpartum following a C-section. What findings should the nurse anticipate?
Answer: heart rate 110/m
439) kosher diet
Answer: Can not ear meat and dairy together
440) a nurse is caring for a pt who is in preterm labor and is receiving betamethasone What
action should the nurse take?
Answer: inject the medication vastus laterials
441) Maternal
Answer: Maternal refers to qualities or behaviors associated with a mother, such as nurturing
and caring.